PATIENT INFORMATION FORM

DATE:

Patient Name:

Last:

First:

MI:

Date of Birth:

AGE:

Sex:

M F

HOME ADDRESS:

CITY:

STATE:

ZIP:

MAY WE LEAVE A MESSAGE?

HOME PHONE #:

Yes No

HOME PHONE #:

CELL PHONE #:

Yes No

CELL PHONE #:

WORK PHONE#

Yes No

WORK PHONE#

MARITAL STATUS:

S M D W

E-MAIL:

SPOUSE:

PRIMARY LANGUAGE:

SOCIAL SECURITY #:

RACE:

ETHNICITY:

DO YOU HAVE A LEGAL GUARDIAN OR POWER OF ATTORNEY?

Yes No

IF YES, PLEASE PROVIDE NAME:

EMERGENCY CONTACT:

RELATIONSHIP:

PHONE #:

PRIMARY CARE DOCTOR:

PHONE:

PHARMACY:

LOCATION:

PHONE #:

IS THERE A FAMILY MEMBER OR OTHER PERSON YOU WOULD LIKE FOR US TO SHARE YOUR MEDICAL INFORMATION?

Yes No

If yes, please provide name and phone number:

Name:

PHONE#:

Add new name and phone number

WHO IS RESPONSIBLE FOR PAYMENT?

RELATIONSHIP TO PATIENT?

ADDRESS:

CITY:

STATE:

ZIP:

PHONE #:

WHO REFERRED YOU TO US?

INSURANCE INFORMATION

PRIMARY INSURANCE COMPANY NAME:

ADDRESS:

CITY:

STATE:

ZIP:

PHONE #:

SUBSCRIBER NAME:

DATE OF BIRTH:

EMPLOYER:

ID #:

GROUP #:

SECONDARY INSURANCE COMPANY NAME:

ADDRESS:

CITY:

STATE:

ZIP:

PHONE #:

SUBSCRIBER NAME:

DATE OF BIRTH:

EMPLOYER:

ID #:

GROUP #:

PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING (INCLUDE PRESCRIPTIONS, OVER-THE-COUNTER MEDS AND HERBAL SUPPLEMENTS) OR ATTACH LIST:

NAME:

DOSE:

HOW OFTEN DO YOU TAKE?

Add new medications

PLEASE LIST ALL PRIOR SURGERIES:

MAY ATTACH LIST

Add file

Please upload a file

TYPE OF SURGERY:

DATE:

Add new row

SOCIAL HISTORY

MARITAL STATUS:

SINGLE MARRIED PARTNERED SEPARATED DIVORCED WIDOWED

USE OF ALCOHOL:

NEVER NO LONGER USE HISTORY OF ALCOHOL ABUSE

CURRENT USE

TYPE:

PLEASE SELECT:

RARE OCCASIONAL MODERATE DAILY

USE OF TOBACCO:

NEVER QUIT

HOW LONG AGO?

SMOKE:

PACKS/DAY:

FOR HOW MANY YEARS?

USE OF RECREATIONAL DRUGS:

NEVER QUIT

HOW LONG AGO?

TYPE:

CURRENT USE

TYPE:

PLEASE SELECT:

RARE OCCASIONAL MODERATE DAILY

EMPLOYER:

OCCUPATION:

HOW MUCH ARE YOU ON YOUR FEET AT WORK?

10% 25% 50% 75% 100%

EXERCISE:

NEVER RARE OCCASIONAL WEEKLY SEVERAL TIMES A WEEK DAILY

TYPES OF EXERCISE:

HEIGHT:

WEIGHT:

SHOE SIZE:

FAMILY HISTORY (LIST ANY MEDICAL ISSUES THAT RUN IN YOUR FAMILY (HEART,ARTHRITIS,DIABETES, ETC)

MOTHER:

FATHER:

SISTER:

BROTHER:

YOUR MEDICAL HISTORY

ALLERGIES:

MEDICATIONS

If checked, please list:

ANESTHESIA

If checked, please list:

FOODS

If checked, please list:

TAPE

LATEX

SHELLFISH

IODINE

OTHER

NONE KNOWN

DO YOU HAVE ANY OF THE FOLLOWING:

ACID REFLUX

Y N

ANEMIA

Y N

ARTHRITIS

Y N

ASTHMA

Y N

BACK TROUBLE

Y N

BLADDER INFECTIONS

Y N

ABNORMAL BLEEDING

Y N

BLOOD CLOTS

Y N

BLOOD TRANSFUSION

Y N

BRONCHITIS/EMPHYSEMA

Y N

CANCER

Y N

If you answered Cancer as yes, please input type:

DIABETES:

Y N

If you answered Diabetes as yes, please input type:

TYPE 1 TYPE 2

FIBROMYALGIA

Y N

GOUT

Y N

HEART ATTACK

Y N

HEART DISEASE/FAILURE

Y N

HEPATITIS

Y N

HIV+/AIDS

Y N

HIGH BLOOD PRESSURE

Y N

KIDNEY DISEASE

Y N

LIVER DISEASE

Y N

LOW BLOOD PRESSURE

Y N

MIGRAINE HEADACHES

Y N

MITRAL VALVE PROLAPSE

Y N

NEUROPATHY

Y N

OPEN SORES

Y N

PNEUMONIA

Y N

POLIO

Y N

RHEUMATIC FEVER

Y N

SICKLE CELL DISEASE

Y N

SKIN DISORDER

Y N

SLEEP APNEA

Y N

STOMACH ULCERS

Y N

STROKE

Y N

THYROID DISEASE

Y N

TUBERCULOSIS

Y N

OTHER CONDITIONS:

CURRENT PROBLEM

WHAT SPECIFIC PROBLEM BRINGS YOU TO OUR OFFICE TODAY?

LEFT FOOT

TOP OF FOOT

BOTTOM OF FOOT

INSIDE OF FOOT

OUTSIDE OF FOOT

RIGHT FOOT

TOP OF FOOT

BOTTOM OF FOOT

INSIDE OF FOOT

OUTSIDE OF FOOT

HOW LONG AGO DID THIS PROBLEM FIRST START?

TIME FRAME

DAYS WEEKS MONTHS YEARS

DID YOUR PAIN OR PROBLEM:

BEGIN ALL OF A SUDDEN GRADUALLY DEVELOP OVER TIME

HOW WOULD YOU DESCRIBE YOUR PAIN?

NO PAIN

SHARP

DULL

ACHING

BURNING

RADIATING

ITCHING

STABBING

OTHER

OTHER:

SINCE THE TIME YOUR PAIN OR PROBLEM BEGAN, HAS IT:

STAYED THE SAME BECOME WORSE IMPROVED

WHAT MAKES YOUR PAIN OR PROBLEM FEEL BETTER?

WHAT TREATMENTS HAVE YOU HAD FOR THIS PROBLEM?

HOW HAS THIS PROBLEM AFFECTED YOUR LIFESTYLE OR ABILITY TO WORK?

WAS THIS PROBLEM CAUSED BY AN INJURY?

Yes No

If yes, describe:

IF YES, WAS IT A WORK-RELATED INJURY OR AUTO?

Yes No

TO THE BEST OF MY KNOWLEDGE, I HAVE ANSWERED THE QUESTIONS ON THIS FORM ACCURATELY. I UNDERSTAND THAT PROVIDING INCORRECT INFORMATION CAN BE DANGEROUS TO MY HEALTH. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM THE DOCTOR AND OFFICE STAFF OF ANY CHANGES IN MY MEDICAL STATUS.

I ALSO REQUEST THAT PAYMENT OF AUTHORIZED MEDICARE, HMO OR INSURANCE BENEFITS BE MADE EITHER TO ME OR ON MY BEHALF TO LANCASTER COUNTY PODIATRY FOR ANY SERVICES FURNISHED ME BY PHYSICIAN OR SUPPLIER. I AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION ABOUT ME TO RELEASE TO THE CENTERS FOR MEDICARE SERVICES AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR THE BENEFITS PAYABLE FOR RELATED SERVICES. I AUTHORIZE LANCASTER COUNTY PODIATRY, ITS EMPLOYEES OR MEDICAL PROVIDERS TO RELEASE ALL INFORMATION FROM MY MEDICAL RECORD THAT MAY BE REQUIRED FOR PAYMENT OF MY CHARGES BY MY INSURANCE COMPANY. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE TO PAY FOR ANY CHARGES NOT COVERED BY OTHER SOURCES.

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 OF PATIENT, PARENT OR GUARDIAN

IF OTHER THAN PATIENT, RELATIONSHIP TO PATIENT

DATE

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