Welcome Form

PATIENT INFORMATION

Date

Patient Name

Last:

Middle Initial

Address

City

State

Zip

E-mail

Sex

Male Female

Age

Birthdate

Maritial Status

Married

Separated

Widowed

Divorced

Single

Partnered

Minor

Patient Employer/School

Employer/School Address

Employer/School Phone

Spouse’s Name

Birthdate

Whom may we thank for referring you?

PHONE NUMBERS

Home Phone

Cell Phone

Best time and place to reach you

IN CASE OF EMERGENCY, CONTACT

Name

Relationship

Home Phone

Work Phone

PRIVACY INFORMATION

Any contact information listed on this form, including phone numbers and email, will be used by this office to contact you about future appointments, billing, and routine correspondence.

Consent for Others to Access Your Account & Records

I give my consent for

(i.e. spouse, partner, adult child, etc.) to discuss and/or obtain my NOPArelated medical and account information in person, by phone, or by mail. I understand I may revoke given consent either in writing or in person at any time.

Patient/Guardian signature:

Date

PODIATRIC HISTORY

What is the chief complaint for which you came to be treated? (Include foot, ankle, knee, thigh, and hip complaints.)

Have you been to a podiatrist before?

Yes No

If yes, please list

Name

Last Visit

Is there any personal or family history of diabetes?

Yes No

Your occupation

Cigarette/Tobacco use

Years you smoked

Athletic activities in which you participate (list and indicate frequency)

Please indicate which problems you now have or have had in the past.

Ankle Pain

Yes No

Athlete’s Foot

Yes No

Bunions

Yes No

Corns and Calluses

Yes No

Cramps in Feet or Legs

Yes No

Flat Feet

Yes No

Heel Pain

Yes No

Ingrown Toenails

Yes No

Numbness in Feet or Legs

Yes No

Plantar Warts

Yes No

Swelling in Ankles or Feet

Yes No

Tired Feet

Yes No

MEDICAL HISTORY

Please indicate if you have had any of the following:

AIDS/HIV

Yes No

Allergies to Anesthetics

Yes No

Allergies to Medicine or Drugs

Yes No

Anemia

Yes No

Angina

Yes No

Arthritis

Yes No

Artificial Heart Valves or Joints

Yes No

Asthma

Yes No

Back Problems

Yes No

Bleeding Disorders

Yes No

Cancer

Yes No

Chemical Dependency

Yes No

Chest Pain

Yes No

Chronic Diarrhea

Yes No

Circulatory Problems

Yes No

Diabetes

Yes No

Ear Problems

Yes No

Epilepsy

Yes No

Eye Problems

Yes No

Fainting

Yes No

Gout

Yes No

Headaches

Yes No

Heart Disease

Yes No

Hemophilia

Yes No

Hepatitis/Jaundice

Yes No

High Blood Pressure

Yes No

Kidney Problems

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Neuropathy

Yes No

Phlebitis

Yes No

Psychiatric Care

Yes No

Radiation Treatment

Yes No

Rash

Yes No

Respiratory Disease

Yes No

Radio buttons

Yes No

Shortness of Breath

Yes No

Sinus Problems

Yes No

Special Diet

Yes No

Stroke

Yes No

Swollen Neck Glands

Yes No

Tuberculosis

Yes No

Ulcers

Yes No

Varicose Veins

Yes No

Venereal Disease

Yes No

Weight Loss, unexplained

Yes No

Surgeries You Have Had

Hospitalizations Other Than for the Surgeries Listed

Family Physician

Last Visit Date

Are you now or have you ever been under any other doctor’s care for any reason over the past two years?

Yes No

If yes, please explain

MEDICATIONS

Include prescriptions, over-the-counter medications, and vitamins:

Pharmacy Name(s)

Pharmacy Phone(s)

Do you take oral contraceptives?

Yes No

ALLERGIES

TREATMENT CONSENT

I hereby consent and give my permission to the doctor (and the doctor’s assistants or designated replacement) to administer and perform such procedures upon me or my minor child as the doctor deems necessary.

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 of Patient, Parent, Guardian, or Personal Representative

Date

Printed name of Patient, Parent, Guardian, or Personal Representative

Relationship to Patient

Your information will be encrypted.