Patient Intake Form

Patient Intake Form
Current Date

MonthDayYear
Patient Information
Patient Name*
Patient Date of Birth*

MonthDayYear
Age
Address
Home Phone
Work Phone
Cell Phone
Email Address
Gender

MaleFemale
Marital Status

SingleMarriedDivorcedWidowed
Spouse
Occupation
Your Employer
Employer's Address
Family Doctor's Name
Doctor's Phone Number
Doctor's Address
Insurance Information
Primary Insurance
Secondary Insurance
Subscriber Name
Subscriber Date of Birth

MonthDayYear
Relationship to Patient
Employer
Phone Number
Emergency Contact
Emergency Contact Phone Number
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?

YesNo
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:

None Apply
Medical Conditions:

Diabetes (Diet/Oral/Insulin)Gastric Reflux/Hiatal HerniaKidney DiseaseSkin Problems/PsoriasisAnemiaGoutPeripheral Vascular DiseaseFibromyalgiaArthritis (Rheumatoid/Osteoarthritis/Lupus)Fainting/SeizuresLiver Disease/Hepatitis/JaundiceNeuropathyHigh Blood PressureAnxietyGI Ulcers/Stomach ProblemsDepressionBlood Disease/Bleeding DisordersBroken Bones in Feet/LegsArtificial Heart Valves/Artificial JointsCancer (please specify below)Heart Disease/Angina/Chest PainChemical DependencyVaricose VeinsWeight Loss/Gain (Unexplained)EpilepsyBack Problems/Herniated DiscsHypothyroidism/Thyroid ProblemsStenosisAutoimmune Disease/HIV/AIDSCirculatory ProblemsRheumatic FeverChronic DiarrheaAsthma/Emphysema/Lung ProblemsMSEye PathologyCVA (Stroke)/TIAsCharcot JointHigh CholesterolLeg Cramps/Numbness
What type of cancer?
How many years have you had Diabetes?
If Over 65: Do you have a history of falls?

YesNo
Other Medical Problems (please list):
Surgical History
If no surgical history, please select:

None
Foot Surgery

Yes
Type:
Date

MonthDayYear
Please indicate which side

RightLeft
Surgeries

AngioplastyKnee ReplacementC-SectionCataractCarotid ArteryGall BladderBreast Biopsy/LumpectomyArterial BypassVenous LigationOpen HeartBack SurgeryHernia RepairHip ReplacementAppendectomyMastectomyKidney StonesKidney RemovalPacemakerTonsillectomyProstateHeart BypassD&CHysterectomy
Other Surgical History (please list)
Medications (please list both prescription and non-prescription medications/supplements)
If taking no medications, please select:

None
Pharmacy
Pharmacy Phone
Pharmacy Fax
Family History
Mother

ArthritisDiabetesHeart DiseaseCancerHigh Blood Pressure
Father

ArthritisDiabetesHeart DiseaseCancerHigh Blood Pressure
Siblings

ArthritisDiabetesHeart DiseaseCancerHigh Blood Pressure
Personal or family history of blood clots

YesNo
Details:
Social History
If none apply, please select:

None
Do you drink alcohol?

YesNo
If yes, what kind/s?
Do you use tobacco?

YesNo
If yes, how many packs per day?
Do you drink caffeine?

YesNo
If yes, how many cups/cans/bottles per day?
Do you use recreational drugs?

YesNo
What activities (sports/exercise) do you do?
Allergies
Drug Allergies

NovocainAspirinCodeinePenicillinAdhesive TapeLatexIodineNeosporinMotrin/AdvilCortisoneSulfaNo Known Drug AllergiesOther
Q
K
Bundle
Should be Empty:

Patient Intake Form

Patient Information

Insurance Information

Medical History

Surgical History

Family History

Social History

Allergies