Established Patient Registration

Last Name:

First Name:

Middle Name:

Date of Birth:

Patient Gender:

Male Female

Marital Status:

Single Married Divorced Widowed Separated

Address:

City, State, Zip:

Home Phone:

Cell Phone:

Work Phone:

Social Security:

Email Address:

Race:

Occupation:

Full Time Part Time Retired Disabled

Employer:

Address:

City, State, Zip:

Phone:

Whom may we thank for referring you to our practice?

Family/Friend

Physician Referral

Website

Insurance

Other:

Family/PCP Physician:

Name:

Address:

City, State, Zip:

Phone:

Date last seen:

Pharmacy:

Name:

Address:

City, State, Zip:

Phone#:

Please check all methods we may utilize to speak with you or to leave you a detailed message:

Phone (including auto calls)

Appointment Information

Home

Cell

Work

Medical Information

Home

Cell

Work

TEXT / Email / Patient Portal:

Appointment Information

Medical Information

Send Via Mail

Appointment Information

Medical Information

With another Person(s):

Appointment Information

Medical Information

*** Please sign separate designation for release of medical information form**

Emergency Contact: *****Please list name of someone NOT living in your household*****

Name:

Relationship to Patient:

Phone:

Choose:

Home

Cell

Work

Do you have an advance care plan or surrogate decision maker?

Yes No

Name of custodian of document:

Complete Foot and Ankle Specialists, Inc. does not honor advanced directives. We will call 911 to provide life support to any patient in distress.

After treatment, the patient will be turned over to their treating physician for continuing care and we will provide them with the name of your custodian of document you listed above.

INSURANCE INFORMATION:

*** Insurance Card(s) and photo ID must be given to front desk at time of service ***

Will this treatment be done as a result of?

Workers Compensation Injury:

Yes No

Date of Injury:

Do you have a first report of injury?

Yes No

Physician of Record:

WC Claim #:

Managed Care Organization:

Claims Representative:

Phone #:

Auto/Personal Accident:

Yes No

Date of Injury:

Claim #:

Auto/Homeowners Insurance:

Claims Representative:

Phone #:

Primary Insurance:

Referral Required

Yes No

Policy/ID #:

Group #:

Insured/Subscriber:

Relationship to Patient:

Social Security #:

Date of Birth:

Insured Employer:

Secondary Insurance:

Referral Required

Yes No

Policy/ID #:

Group #:

Insured/Subscriber:

Relationship to Patient:

Social Security #:

Date of Birth:

Insured Employer:

I, the undersigned, certify that I (or my dependent) have coverage with my insurance as presented and assign directly to Complete Foot and Ankle Specialists, LLC all insurance benefits, payable to me for services rendered. I understand that I am responsible for payment of deductibles, co-payments, and/or non - covered services. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize the release of my medical information to my insurance carrier or requested physician to provide continuity of care. I authorize the use of this signature on all insurance submissions. I understand that it is my responsibility to inform Complete Foot and Ankle Specialist, LLC if there is a change in my health insurance information.

I hereby give permission to Complete Foot and Ankle Specialists, LLC to examine, photograph, administer treatment and perform such minor operative procedures as may be deemed necessary in the diagnosis of my foot problem.

Signature:

(If the patient is a minor, the legal guardian must sign)

Date

Patient Name:

Date of Birth:

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

PATIENT MEDICAL INFORMATION

Patient Name:

Date of Birth:

To help us meet your health care needs, please complete the following questionnaire.

Describe your foot/ankle problem (example: right ankle pain):

When did this begin?

Was there an accident or injury?

Yes No

If yes, please describe

How painful is your condition? (Scale: 0 = no pain 10 = extremely painful)

Type of pain:

Burning

Tingling

Sharp

Dull Ache

Shooting

Stabbing

Numbness

Throbbing

When does the pain occur?

Standing

During walking

After walking

During sports

With shoes

Without shoes

Worse with activity

Better after activity

ALWAYS

What makes the pain/condition better (Example: rest, icing, medications, etc.)?

Height:

Weight:

Shoe Size:

Men's

Women's

Smoker?

No Yes

If yes, how long?

How many packs a day?

Quit

Vaping?

No Yes

If yes, how long?

How often?

Quit

Alcohol use?

No Yes

If yes, how often?

Weekly

Occasionally

Rarely

Drug use?

No Yes

If yes, what type?

Marijuana

Illegal Prescription

If you chose Illegal Prescription, what type?

Other:

Have you gotten a flu vaccine this season?

Yes No

Date:

Have you gotten a pneumonia vaccine within the last 5 years?

No Yes

Date:

Any other medical problems not listed above:

NONE OF THE ABOVE

Past SURGERIES with date:

Past HOSPITALIZATIONS with date:

add another past surgery/hospitalization

REVIEW OF SYMPTOMS:

Are you CURRENTLY experiencing any of the following:

GENERAL:

Chills

Fever

Unexplained Weight Gain

Unexplained Weight Loss

EYES:

Eye symptoms

EARS/NOSE/THROAT/MOUTH:

Ear Symptoms

Nasal Symptoms

Throat/Mouth Symptoms

RESPIRATORY:

Shortness of breath

Cough

Congestion

GI:

Changes in appetite

Constipation

Diarrhea

Indigestion

Nausea

Ulcers

Vomiting

GU:

Urinary frequency

Excessive urination

Pain with urination

MUSCULO:

History of falls

Leg cramps

Muscle aches

Tenderness

SKIN:

Skin symptoms

Hair symptoms

Nail symptoms

NEUROLOGIC:

Difficulty with balance

Headache

Lightheadedness

Restless leg syndrome

Stroke

PSYCHIATRIC:

Anxiety

Insomnia

Memory loss

Mood changes

ENDOCRINE:

Dry Skin

Hair loss

Excessive sweating

Excessive thirst

Thyroid problems

HEMA/LYMPH:

Excessive bleeding

Bruising

FAMILY HISTORY: Has any member of your immediate family been treated for the following?

UNKNOWN

MOTHER

FATHER

GRANDMOTHER

GRANDFATHER

MEDICATIONS: Are you currently taking any medications? (Please ATTACH list if needed)

NONE AT THIS TIME

Name of Medication

Strength

Dosage

Frequency

Add new Medication

ALLERGIES: Please CHECK any of the following to which you’ve had ALLERGIC REACTIONS to:

NO KNOWN DRUG ALLERGIES

Aspirin

Codeine

Iodine

Latex

Local Anesthetics (Novocain)

Penicillin

Sulfur

Adhesive

OTHER:

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.

Signature:

Your information will be encrypted.