PATIENT INFORMATION

First Name* Last Name* MI

Address

City State Zip
AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY

Home Phone ()

Work Phone ()

Social Security # - -

Date of Birth* / / (mm/dd/yyyy)     Age

Sex: Male  Female

Marital Status: Single  Married  Widowed  Divorced  Separated 

Employer

Spouse's Name

Who referred you to our office?

Who is your primary physician?

PERSON RESPONSIBLE FOR PAYMENT (if other than patient)

Name Relationship

Address

Home Phone ( )

Work Phone ( )

Employer

EMERGENCY CONTACT

Name Relationship

Phone
( )

INSURANCE INFORMATION

Primary Insurance Company

Policy Holder
Policy #

DOB (mm/dd/yyyy)

Secondary Insurance Company

Policy Holder
Policy #

DOB (mm/dd/yyyy)

MEDICAL INFORMATION

Describe your foot/ankle problem:

How long has it bothered you?

Can you recall any type of injury?

Please rate your pain: 1   2   3   4   5   6   7   8   9   10
(mild) (moderate) (severe)

What makes your condition worse?

What makes your condition better?

Have you tried to treat this condition? (soaks, pads, changing shoes) YES   NO

If yes, please explain:

Have you been treated by another doctor for this problem? YES   NO

If so, who?    When?

Physician's notes:

GENERAL HEALTH INFORMATION

Are you currently under the care of a physician? Y   N

Conditions being treated

Are you DIABETIC? Y   N

If so, how long have you been diabetic?

What is your AM blood sugar range?

Do you currently take INSULIN? Y   N

Check all that you HAVE or HAVE HAD a problem with:

SOCIAL HISTORY

Tobacco use? Y   N

Do you drink alcohol or beer? Y   N

MEDICATIONS (please list all)

1.
2.
3.
4.
5.

ALERGIES (list all that apply)

1.
2.
3.
4.
5.

FAMILY HISTORY (list any significant family illnesses - blood relative)

1.
2.
3.
4.
5.