Download pdf - PATIENT NAME D BIRTH...PATIENT NAME: _____ DATE OF BIRTH: ____/____/_____ Revised June 2015 PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING (INCLUDE PRESCRIPTIONS, OVER-THE-COUNTER

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  • PATIENT NAME: _____________________________ DATE OF BIRTH: ____/____/_____

    Revised June 2015

    PATIENTINFORMATIONFORM(PLEASEPRINT)

    DATE:____/_____/_____PATIENTNAME:______________________________________DATEOFBIRTH:____/____/____AGE:____SEX:MF LAST FIRST MI

    HOMEADDRESS:______________________________________ CITY/STATE:________________________ZIP:_____________

    MAYWELEAVEAMESSAGE?HOMEPHONE#: (_____)_____-________ YESNO WORKPHONE#: (_____)_____-________ YESNO

    CELLPHONE#: (_____)_____-________ YESNO

    E-MAIL:_____________________________________ YESNO

    PRIMARYLANGUAGE:__________________________RACE:___________________________________________ ETHNICITY:____________________________________

    DOYOUHAVEALEGALGUARDIANORHEALTHCAREPOWEROFATTORNEY?YESNO IFYES,NAME:____________________________RELATIONSHIP:_____________PHONE#:(_____)_____-_______

    EMERGENCYCONTACT:____________________________RELATIONSHIP:_____________PHONE#:(_____)_____-_______

    PRIMARYCAREDOCTOR:___________________________________________PHONE:__________________________________PHARMACY:_____________________________LOCATION:__________________________PHONE#:(_____)_____-_______

    ISTHEREAFAMILYMEMBEROROTHERPERSONYOUWOULDLIKEFORUSTOSHAREYOURMEDICALINFORMATION?NO______YES_____NAME(S)___________________________________________________________________________________

    WHOISGUARANTORFORPAYMENT?______________________DOB:__________RELATIONSHIPTOPATIENT?__________

    ADDRESS:________________________CITY/STATE:_________________ZIP:_________PHONE#:(_____)_____-______HOWDIDYOUHEARABOUTOUROFFICE?________________________________________________________________________INSURANCEINFORMATION

    PRIMARYINSURANCECOMPANYNAME:_________________________________________________________________________

    ADDRESS:________________________CITY/STATE:_________________ZIP:_________PHONE#:(_____)_____-______

    INSUREDNAME:__________________________DATEOFBIRTH______________EMPLOYER___________________________

    CONTRACT#__________________GROUP#____________________SECONDARYINSURANCECOMPANYNAME:_______________________________________________________________________

    ADDRESS:________________________CITY/STATE:_________________ZIP:_________PHONE#:(_____)_____-______

    INSUREDNAME:__________________________DATEOFBIRTH______________EMPLOYER___________________________

    CONTRACT#__________________GROUP#____________________

  • PATIENT NAME: _____________________________ DATE OF BIRTH: ____/____/_____

    Revised June 2015

    PLEASELISTALLMEDICATIONSYOUARECURRENTLYTAKING(INCLUDEPRESCRIPTIONS,OVER-THE-COUNTERMEDSANDHERBALSUPPLEMENTS):NAME DOSE HOWOFTENDOYOUTAKE?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PLEASELISTALLPRIORSURGERIES:TYPEOFSURGERY DATE TYPEOFSURGERY DATE__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PLEASELISTALLPRIORHOSPITALIZATIONS(OTHERTHANFORSURGERY):REASONFORHOSPITALIZATION DATE REASONFORHOSPITALIZATION DATE__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________IMMUNIZATION/DATEOFADMINISTRATIONINFLUENZA:________________________________________________________________________________________________PNEUMONIA:__________________________________________________________________________________________________SOCIALHISTORYMARITALSTATUS:cSINGLEcMARRIEDcPARTNEREDcSEPARATEDcDIVORCEDcWIDOWED

    USEOFALCOHOL:cNEVERcNOLONGERUSEcHISTORYOFALCOHOLABUSEcCURRENTUSE-TYPE__________________cRAREcOCCASIONALcMODERATEcDAILY

    USEOFTOBACCO:cNEVERcQUIT–HOWLONGAGO?_________cSMOKE____PACKS/DAYFOR____YEARS

    USEOFRECREATIONALDRUGS:cNEVERcQUIT–HOWLONGAGO?_________TYPE_______________________

    cCURRENTUSE-TYPE_______________cRAREcOCCASIONALcMODERATEcDAILY

    EMPLOYER:_______________________________________OCCUPATION:____________________________________________

    HOWMUCHAREYOUONYOURFEETATWORK?c10%c25%c50%c75%c100%

    TYPESOFSHOESFORWORK/PLAY:____________________________________________________________________________TYPESOFSHOESFORHOME:__________________________________________________DOYOUGOBAREFOOTED:YN

    EXERCISE:cNEVERcRAREcOCCASIONALcWEEKLYcSEVERALTIMESAWEEKcDAILY

    TYPESOFEXERCISE:_____________________________________________________________________________________

  • PATIENT NAME: _____________________________ DATE OF BIRTH: ____/____/_____

    Revised June 2015

    FAMILYHISTORYDOYOUHAVEAFAMILYHISTORYOF:cDIABETES:TYPE1ORTYPE2cCANCER_________cHEARTDISEASEcHIGHBLOODPRESSUREcSTROKEcCORONARYARTERYDISEASEcTHYROIDDISEASEcRHEUMATOIDARTHRITIScOTHER_____________________________________________________________________YOURMEDICALHISTORY:HEIGHT:___________________WEIGHT:________________________ALLERGIES:cMEDICATIONS__________________________________cNONEKNOWN

    cANESTHESIA_________________________________cFOODS____________________________________cTAPEcLATEXcSHELLFISHcIODINEcOTHER_______________________________________

    HAVEYOUEVERHADANYOFTHEFOLLOWING?ACIDREFLUX Y N FIBROMYALGIA Y N NEUROPATHY Y NANEMIA Y N GOUT Y N PACEMAKER Y NARTHRITIS Y N HEARTATTACK Y N PNEUMONIA Y NASTHMA Y N HEARTDISEASE/FAILURE Y N POLIO Y NBACKTROUBLE Y N HEPATITIS Y N REFLUX/GERD Y NBLADDERINFECTIONS Y N HIV+/AIDS Y N SICKLECELLDISEASE Y NABNORMALBLEEDING Y N HIGHBLOODPRESSURE Y N SKINDISORDER Y NBLOODCLOTS/FILTER Y N KIDNEYDISEASE Y N SLEEPAPNEA Y NBLOODTRANSFUSIONBLEEDINGDISORDERS

    YY

    NN

    LIVERDISEASELOWBLOODPRESSURE

    YY

    NN

    STOMACHULCERS/IBSCROHN’S

    YY

    NN

    BRONCHITIS/EMPHYSEMA Y N JOINTREPLACEMENTS Y N SEIZURESSTROKE

    YY

    NN

    CANCERTYPE: Y N MIGRAINEHEADACHES Y N THYROIDDISEASE Y NDIABETES:TYPE1ORTYPE2(CIRCLE)

    Y N MITRALVALVEPROLAPSE

    Y N TUBERCULOSIS Y N

    OTHERCONDITIONS:

    CURRENTPROBLEMWHATSPECIFICPROBLEMBRINGSYOUTOOUROFFICETODAY?__________________________________________________

    WHEREISTHEPAIN/PROBLEMLOCATED?PLEASEMARKONTHEPICTURESBELOW. LEFTFOOT RIGHTFOOT

    INSIDEOFFOOTOUTSIDEOFFOOTOUTSIDEOFFOOTINSIDEOFFOOT

    TOPOFFOOTBOTTOMOFFOOTBOTTOMOFFOOTTOPOFFOOT

  • PATIENT NAME: _____________________________ DATE OF BIRTH: ____/____/_____

    Revised June 2015

    HOWLONGAGODIDTHISPROBLEMFIRSTSTART?__________DAYS/WEEKS/MONTHS/YEARS

    DIDYOURPAINORPROBLEM:cBEGINALLOFASUDDEN cGRADUALLYDEVELOPOVERTIME

    HOWWOULDYOUDESCRIBEYOURPAIN?cNOPAINcSHARPcDULLcACHINGcBURNINGcRADIATINGcITCHINGcSTABBINGcOTHER________________________________________________

    HOWWOULDYOURATEYOURPAINONASCALEFROM0TO10?(PLEASECIRCLE)(NOPAIN)012345678910(WORSTPAINPOSSIBLE)

    SINCETHETIMEYOURPAINORPROBLEMBEGAN,HASIT:cSTAYEDTHESAMEcBECOMEWORSEcIMPROVED

    WHATMAKESYOURPAINORPROBLEMFEELWORSE?cWALKINGcSTANDINGcDAILYACTIVITIEScRESTINGcDRESSSHOEScHIGHHEELScFLATSHOEScANYCLOSEDTOESHOEcRUNNINGcOTHER________________________________________________________________________________

    WHATMAKESYOURPAINORPROBLEMFEELBETTER?____________________________________________________________

    WHATTREATMENTSHAVEYOUHADFORTHISPROBLEM?_________________________________________________________

    HOWHASTHISPROBLEMAFFECTEDYOURLIFESTYLEORABILITYTOWORK?_______________________________________

    WASTHISPROBLEMCAUSEDBYANINJURY?cYES(DESCRIBE)_________________________________________cNO

    IFYES:WORKAUTOOTHERINJURY____________________

    CLAIM#________________________________WHEREWASITFILED_______________________________________TOTHEBESTOFMYKNOWLEDGE,IHAVEANSWEREDTHEQUESTIONSONTHISFORMACCURATELY.IUNDERSTANDTHATPROVIDINGINCORRECTINFORMATIONCANBEDANGEROUSTOMYHEALTH.IUNDERSTANDTHATITISMYRESPONSIBILITYTOINFORMTHEDOCTORANDOFFICESTAFFOFANYCHANGESINMYMEDICALSTATUS.___________________________________________________ ___________________________________________________PRINTNAMEOFPATIENT,PARENTORGUARDIAN SIGNATUREOFDOCTOR___________________________________________________ ___________________________________________________IFOTHERTHANPATIENT,RELATIONSHIPTOPATIENT DATE____________________________________________________SIGNATURE_____________________________________________DATE


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