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MEDICAL HISTORY

SS/HIC/Patient ID #:
Date:
First: Last: Date of Birth: Age:
Sex:
Address: City: State: Zip:
E-mail: Married Widowed Single Minor Separated Divorced Partnered
Home Phone: Cell Phone: Best time and place to reach you:

 

In case of emergency, contact

 

Name: Relationship: Phone:

 

Insurance:

Who is responsible for this account? Relationship to Patient:

Insurance Company: Group #:

Is patient covered by additional insurance? Yes No

Subscriber's Name: Birthdate: SS#:

Relationship to Patient: Insurance Company: Group #:

Insurance assignment and release

I certify that I have insurance coverage and assign directly to Dr. all Insurance benefits. If any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named doctor may use my health care information and may disclose such information to the above named insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Medicare/Medigap authorization

I request that payment of authorized Medicare benefits and, if applicable Medigap benefits, be made either to me or on my behalf to for any services furnished to me by that provider.

To the extent permitted by law, I authorize any holder of medical or other information about me to release to the Centers for Medicare and Medicaid Services, my Medigap insurer, and their agents any information needed to determine these benefits for related services.

Signature of Patient, Parent, Guardian or Personal Representative
Date

 

Please print name of Patient, Parent, Guardian or Personal Representative
Relationship to Patient

 

Podiatric History:

What is the chief complaint for which you came to be treated? (Include foot, ankle, knee, thigh, and hip complaints)

 

Have you ever been to a Podiatrist before?

Yes No

If yes, please list.

Name:

Last visit:

 

 

Is there any personal or family history of diabetes?

Yes No

 

Your occupation: Cigarette/Tobacco use:

Years smoked:

 

Athletic activities in which you participate (please list and indicate frequency)

Ankle Pain

Athelete's Foot

Bunions

Corns and Calluses

Cramps or Numbness

Flat Feet

Foot or Leg Cramps

Heel Pain

Ingrown Toenails

Plantar Warts

Swelling in Ankles or Feet

Tired Feet

 

Place a mark to indicate if you have had any of the following:

AIDS/HIV

Allergies to Anesthetics

Allergies to Medicine or Drugs

Anemia

Angina

Arthritis

Artificial Heart Valves or Joints

Asthma

Back Problems

Bleeding Disorders

Cancer

Chemial Dependency

Chest Pain

Chronic Diarrhea

Circulatory Problems

Diabetes

Ear Problems

Epilepsy

Eye Problems

Fainting

Foot or Leg Cramps

Gout

Headaches

Heart Disease

Hemophillia

Hepatitis or Jaundice

High Blood Pressure

Kidney Problems

Liver Disease

Low Blood Pressure

Neuropathy

Phlebitis

Psychiatric Care

Radiation Treatment

Rash

Respiratory Disease

Rheumatic Fever

Shortness of Breath

Special Diet

Stroke

Swelling in Anlkes, Feet

Swollen Neck Glands

Tired Feet

Tuberculosis

Ulcers

Varicose Veins

Venereal Disease

Weight Loss, unexplained

Others:

 

Surgeries you have had:

 Hospitalization other than for the surgeries listed:

 

Family physician: Last visit date:

 

Are you now, or have you been, under any other doctor's care for any other reason over the past two years? Yes No

If yes, please explain:

 

MEDICATIONS
ALLERGIES

Include prescriptions, over-the-counter medications and vitamins:

 

Pharmacy Name(s):

 

Pharmacy Pnone(s): ( )

 

Do you take oral contraceptives? Yes No

Adhensive/Tape

Anticoagulant

Aspirin

Codeine

Demerol

Iodine

Local Anesthetics

Novocaine

Penicillin

Seafoods

Sulfa

Others:

 

 

TREATMENT CONSENT

I hereby consent and give my permission to the doctor (and the doctor's assistants or designated replacement) to administer and perform such procedures upon me as the doctor seems necessary.

Signature of Patient, Parent, Guardian or Personal Representative
Date

Please print name of Patient, Parent, Guardian or Personal Representative
Relationship to Patient