Last Name

First Name

Middle Initial

Today’s Date

Spouse/Parent/Guardian’s Name

Spouse’s Birthday

Spouse’s Employer

Patient DOB

Patient’s Age

Residence Address

City

State

Zip

Marital Status

Single   Married   

Widowed Divorced 

Home Phone

Patient’s Social Security No.

Driver’s License No.

Email Address

Name of Employer & Address

Occupation

Business Phone

Whom may we thank for referring you?

Address

Name, address and phone of contact in case of emergency

Relationship

If other than patient, name and address of person responsible for this account

Do you have                Yes

Medical Insurance       No

Carrier Name

Subscriber Name

Policy No.

Group No.

Is it through your employer

Yes      No

Is there secondary insurance?

  Yes    No

Carrier Name

 

Subscriber Name

Policy No.

List any medical conditions you have (allergies, impairments, etc.)

Name of family physician

Phone

Are you currently under    Yes

Your physician’s care       No

If yes, for what

May we contact your physician           Yes

For your health records                       No

Have you had previous          Yes

Treatment by a podiatrist        No

When

For What

My chief foot complaint is:

My condition(s) have existed for:

Days

Weeks

Months

Years

What medicines do you take regularly:
Do you have or have you had any of the following: (*do not know) Are you allergic or sensitive to:
   Yes No DNK      Yes No DNK           Yes No DNK      Yes No DNK
Foot or leg injuries Diabetes        Anemia Novocain
Foot or leg surgery Heart trouble        Gout Penicillin
Foot or leg cramps Epilepsy        Fainting spells Adhesive tape
Foot or leg numbness Liver disease        Bleeder Materials
Knee pain Kidney disease        Blood disease Drugs
Unequal leg length Rheumatic fever        Circulation problems Foods
Weak Ankles High blood pressure        Hardening of arteries Other describe
Bunions Polio        Varicose veins _____________________
Foot skin problems Bursitis        Arthritis _____________________
Toe nail problems Stomach ulcers        Cancer _____________________
Low back pain Asthma        Prone to infection _____________________

I hereby give Dr. _____________________________ permission to examine and treat my feet.

_____________________________________________________ _____________________________________
Patient, Parent, or Guardian's Signature                                            Date