New Patient Forms

Dr. Timothy J Brown FACFAS, Dr. Andrew J. Brown FACFAS, Dr. Matthew J. Brown FACFAS

PATIENT HISTORY

Last name

First name

Middle Initial

SS#

Date

Name: Spouse, Parent or Guardian

By what name do you wish to be addressed?

Date of Birth

Age

Home Phone Number

Cell Phone Number

Address

City, State, Zip

Whom may we thank for referring you to our office?

Emergency Contact

Relationship

Phone

Marital Status

Single Married Widowed Divorced

Primary Insurance

Insured Name

Insured DOB

Relationship

Secondary Insurance

Insured Name

Insured DOB

Relationship

Address of insured if different than the patient:

I have given permission for a message to be left with:

Family members: Yes

If yes, list family members below

Family members: No On answering machine: Yes On answering machine: No

Family members:

PODIATRIC HISTORY

Patient's name

Date:

Name of Family Physician

City/State

Last visit

Family History: Siblings: Alive

Yes No

If no, cause of death and age below:

Cause of death/age

Mother alive

Yes No

If no, cause of death and age below:

Cause of death/age

Father alive

Yes No

If no, cause of death and age below:

Cause of death/age:

Past surgical history, date, surgeons, location of surgery, procedure and outcome:

Past Anesthesia history: Local/Date/problems?

Past Anesthesia history: General/Date/problems?

Current medications (strength & dosage)

Height

Weight

Shoe size

Diabetes: Do you test glucose every day?

Yes No

Recreational Drug Use

Yes No

Do you smoke? If so, how much and for how long?

Do you drink alcohol? If so, how much and how often?

Females: are you pregnant? Have you had a hysterectomy? If so, when?

Chief complaints

Nature of pain:

Sharp

Burning

Dull ache

Sore

Throbbing

Bruised

Pins & needles

Location of pain or lesion:

Onset:

Sudden Gradual

Duration:

Frequency:

Constant Intermittent

Timing:

Weight bearing

Non-weight bearing

Shoe aggravate

During work

Date of injury

Expectations of today's visit

SYMPTOMS

Constitutional Systems

Good general health

Yes No

Recent weight change

Yes No

Fever

Yes No

Fatigue

Yes No

Eyes

Eye disease

Yes No

Wear glasses/contact lenses

Yes No

Blurred/Double Vision

Yes No

Glaucoma

Yes No

Ears/Nose/Mouth/Throat

Hearing loss or ringing

Yes No

Earaches or drainage

Yes No

Chronic Sinus Problems or Rhinitis

Yes No

Nose bleeds

Yes No

Mouth sores

Yes No

Bleeding gums

Yes No

Bad breath or bad taste

Yes No

Sore throat or voice changes

Yes No

Swollen glands in neck

Yes No

Cardiovascular

Heart trouble

Yes No

Chest pain or Angina Pectoris

Yes No

Palpitation

Yes No

Shortness of breath with walking/laying flat

Yes No

Swelling of feet, ankles, hands

Yes No

Atrial Fibrillation

Yes No

Respiratory

Chronic or frequent coughs

Yes No

Spitting up blood

Yes No

Shortness of breath

Yes No

Asthma or wheezing

Yes No

Gastrointestinal

Loss of appetite

Yes No

Change in bowel movements

Yes No

Nausea or vomiting

Yes No

Frequent diarrhea

Yes No

Painful bowel movements or constipation

Yes No

Rectal bleeding/blood in stool

Yes No

Abdominal pain or heartburn

Yes No

Peptic ulcer (stomach/duodenal)

Yes No

Genitourinary

Frequent urination

Yes No

Burning or painful urination

Yes No

Blood in urine

Yes No

Musculoskeletal

Joint pain

Yes No

Muscle pain or cramps

Yes No

Back pain or back injury

Yes No

Difficulty walking

Yes No

Joint stiffness/swelling

Yes No

Weakness of a muscle or joint

Yes No

Rheumatoid Arthritis

Yes No

Integumentary (Skin/Breast)

Rash or itching

Yes No

Change in skin color

Yes No

Change in hair or nails

Yes No

Varicose veins

Yes No

Neuorological

Frequent or recurring headaches

Yes No

Light-headed or dizzy

Yes No

Convulsions or seizures

Yes No

Numbness/tingling sensation

Yes No

Tremors

Yes No

Paralysis

Yes No

Stroke

Yes No

Head injury

Yes No

Psychiatric

Memory loss or confusion

Yes No

Nervousness

Yes No

Depression

Yes No

Insomnia

Yes No

Anxiety

Yes No

Panic attacks

Yes No

Endocrine

Glandular/hormone problems

Yes No

Thyroid disease

Yes No

Diabetes Insulin/Non-insulin?

Yes No

Excessive thirst/urination

Yes No

Skin becoming dryer

Yes No

Hematological/Lymphatic

Slow to heal after cuts

Yes No

Bleeding/bruising tendency

Yes No

Anemia

Yes No

Phlebitis

Yes No

Past transfusion

Yes No

Enlarged glands

Yes No

History of skin reaction or other adverse reaction to Penicillin, Sulfa, other antibiotic

Yes No

Reaction to Morphine, Demerol, or other narcotics

Yes No

Reaction to novacaine or other anesthetics

Yes No

Reaction to aspirin or other pain remedies

Yes No

Reaction to other drug/medications

Yes No

Food allergies?

Yes No

Latex allergies?

Yes No

Your information will be encrypted.

New Patient Forms

PATIENT HISTORY

PODIATRIC HISTORY

SYMPTOMS

Ankle and Foot Specialists of Marion