ACTIVE PODIATRY

Patient’s Name:

Date:

Home Phone

Email:

Mobile Phone:

Address:

City:

State:

Zip:

Birth Date:

Gender

Male Female

Social Sec. #:

Marital Status:

Patient’s Employer:

Employer Phone:

If minor, responsible party name:

Relationship:

Birth Date:

Gender:

Male Female

Social Sec. #:

Marital Status:

Address:

City:

State:

Zip:

Resp. Party Employer:

Employer Phone:

MEDICAL INSURANCE INFORMATION

Check if Not Insured

Primary Insurance Co.:

Name of Insured:

Insured’s Social Sec. #:

Insured’s Date of Birth:

Patient’s Relationship to Insured:

Self Spouse Child

Other:

Secondary Insurance Co.:

CURRENT COMPLAINT

Reason for seeing doctor today:

Duration of current condition:

Have you had any treatments for your current condition?

Yes No

If yes, explain:

Have you seen a podiatrist before?

Yes No

If yes, Doctor’s name:

Date last seen:

MEDICAL HISTORY

Other:

SURGICAL HISTORY

Please list any surgeries you have had:

Date of Surgery:

SOCIAL HISTORY

Height:

Weight:

Shoe Size:

Age:

Dominant Hand:

Do You Smoke?

No Yes

Pack/day

Former Smoker?

No Yes

Alcohol Use:

None Occasional Mild/Moderate Heavy

Exercise:

None Occasional Regular Light Regular Moderate Regular Heavy

Occupation:

Activity Level:

N/A Sedentary Mild/Moderate Activity Very Active

CURRENT MEDICATIONS

Medication

Dosage

Frequency

Add new Medications

Do you have any allergies?

No Yes

Other

Any Other Pertinent Medical / Familial History or Information?

Primary Care Physician:

Date Last Seen

Address:

City:

Zip:

Preferred Pharmacy:

Address:

In case of emergency, please contact:

Name:

Relationship:

Phone:

Address:

REFERRED BY:

Doctor:

Address:

City:

Zip:

Patient or Friend (please list):

Insurance

Internet (please specify)

Our Website

Google

Yahoo

Bing

Other Referral Source:

Other (please list)

I certify that the above information is true and correct to the best of my knowledge.

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

Name/Signature:

Date:

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