Patient Information Form

Name

Date of Birth:

Age:

Address:

Apt# City:

State:

Zip:

Sex:

Male Female

Status

Married Single Widowed Other

Language:

Ethnicity/Nationality:

Phone: Home

Work

Cell

Email:

Employer:

Occupation:

EMERGENCY CONTACT

Name:

Relationship:

Phone: Home

Work:

Cell:

Responsible Party/Primary Insurance Company Name:

Name of Insured:

Date of Birth

Relationship:

ID #:

Group #:

Employer:

Employer Phone:

Secondary Insurance Company Name:

Name of Insured:

Date of Birth:

Relationship:

ID #:

Group #:

Employer:

Employer Phone:

What is the reason for your visit today?

How were you referred to our office?

I certify that the information given above is true and correct. I understand that it is my responsibility to notify West Hartford Podiatry Associates of any changes to the above information.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient or Guardian Signature:

Date:

HISTORY & MEDICAL INFORMATION

1. Primary Care Physician

Phone Number:

Date of Last Visit:

2. Explain your foot/ankle problem:

3. When did the pain/discomfort begin?

Describe the pain/discomfort:

Burning Numbness Sharp Other

If Other, Please specify:

4. What makes the pain/discomfort better?

5. What makes the pain/discomfort worse?

6. Has the condition been treated?

Yes No

When:

How:

If Other, Please Specify:

8. List all Medications/herbs/vitamins:

Medications/Herbs.Vitamins

None

Add more

What is your Pharmacy’s name?

Phone #:

9. Allergies

NONE

Penicilin

Narcotic Agent/Codeine

Sulfa Drugs

Aspirin

Anethesia

Radiographic Contrast/Dyes

Shellfish

Other

If Other, Please Specify.

10. Surgical History:

Have you had surgery?

Yes No

Describe (Surgery/Date):

11. Social History

Tobacco Use

Caffeine Use

Alcohol Use

Drug Use (Recreational, IV)

Exercise Habits

if Yes, How much?

Pregnant

Nursing

12. Occupation/Job:

If Other Family History, Please Specify

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