Patient Intake Form

Patient Intake Form
Current Date

MonthDayYear
Patient Information
Patient Name
Patient Date of Birth

MonthDayYear
Age
Address
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Email Address
Gender
Marital Status
Spouse
Occupation
Your Employer
Employer's Address
Family Doctor's Name
Doctor's Phone Number
Format: (000) 000-0000.
Doctor's Address
Insurance Information
Primary Insurance
Secondary Insurance
Subscriber Name
Subscriber Date of Birth

MonthDayYear
Relationship to Patient
Employer
Phone Number
Format: (000) 000-0000.
Emergency Contact
Emergency Contact Phone Number
Format: (000) 000-0000.
Whom may we thank for referring you?
I authorize Dr. Farrell, Dr. Rounds, Dr. Smith, Dr. Wadie, Dr. Stanley, Dr. Beabes, Dr. Bersani to provide any insurance company, claim administrator, and consulting health care professionals, information concerning health care, advice, treatment, or supplies provided. This information will be used for the purpose of evaluating and administrating claims for benefits. I hereby authorize payment directly to Dr. Farrell, Dr. Rounds, Dr. Smith, Dr. Wadie, Dr. Stanley, Dr. Beabes, and Dr. Bersani and their assistants to diagnose, administer medications, and perform such procedures as may be deemed necessary in the diagnosis/treatment of my feet and related conditions. I understand and agree that because of human variance and response it is not possible to warrant the outcome of any medical care or service.
Responsible Party Signature

Clear
Relationship to Patient
Please be advised that our office has a 24 hr. cancellation policy. Failure to notify our office if you are unable to keep your appointment will result in a fee of $50 for new patients and $30 for established patients.
Height
Weight
Have you had a Flu shot in the past 8 months?
Reason for Visit
Date of Onset

MonthDayYear
Primary Medical Doctor
Date Last Seen

MonthDayYear
Doctor Treating for Diabetes
Date Last Seen

MonthDayYear
Former Podiatrist
Date Last Seen

MonthDayYear
Medical History
If none apply, please select:
Medical Conditions:
What type of cancer?
How many years have you had Diabetes?
If Over 65: Do you have a history of falls?
Other Medical Problems (please list):
Surgical History
If no surgical history, please select:
Foot Surgery
Type:
Date

MonthDayYear
Please indicate which side
Surgeries
Other Surgical History (please list, separated by commas. eg. surgery 1, surgery 2)
Calculation: Surgical History
Medications (please list both prescription and non-prescription medications/supplements, separated by commas. eg. medication 1, medication 2)
If taking no medications, please select:
Pharmacy
Pharmacy Phone
Format: (000) 000-0000.
Pharmacy Fax
Format: (000) 000-0000.
Family History
Mother
Father
Siblings
Personal or family history of blood clots
Details:
Social History
If none apply, please select:
Do you drink alcohol?
If yes, what kind/s?
Do you use tobacco?
If yes, how many packs per day?
Do you drink caffeine?
If yes, how many cups/cans/bottles per day?
Do you use recreational drugs?
What activities (sports/exercise) do you do?
Allergies
Drug Allergies

Other
Q
K
Bundle
Should be Empty:

Patient Intake Form

Patient Information

Insurance Information

Medical History

Surgical History

Family History

Social History

Allergies