New Patient Forms

PATIENT HISTORY

Today's Date:

Patient's Name:

/Spouse:

Social Security No:

Email address:

Address: (Street)

City:

State:

Zip:

Home Phone:

Business Phone:

Date of Birth:

Marital Status:

Occupation:

Employer:

Spouse Occupation:

Spouse Employer:

Guardian's Name (if patient is a minor):

Address (if different than parent's):

City:

State:

Zip:

Person to contact in case of emergency:

Phone:

Address:

City:

State:

Zip:

Referred by:

Insured by:

What is your foot problem?

When did this problem start?

Have you had foot treatment before?

Yes No

If yes, by whom?

What was the treatment?

How have you treated this problem at home?

Have you injured your feet before?

Yes No

and if so, how?

What type of work do you do?

Please answer the following questions to the best of your ability:

Your:

Height:

Weight:

Shoe size:

Are you in:

good health fair health poor health

Are you subject to prolonged bleeding or healing difficulties?

Yes No

Do you bruise easily?

Yes No

Do you have low back pain?

Yes No

Are you under the care of a doctor?

Yes No

If yes, state the reason:

Physician’s name:

Address:

City:

State:

Zip:

Are you on a diet?

Yes No

What medications are you now taking?

Add new medication

Do you:

smoke (amount):

drink alcohol (amount):

l am not allergic to anything to my knowledge

I am allergic to (please select all that apply)

If other, please specify:

If you have not had diabetes, are you aware of any family member who has had it?

Yes No

If so, who?

Is there anything else we should know?

Yes No

If yes, please specify:

I hereby give permission to Dr. Andrew H. Cohen to treat my foot condition.

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.

Date:

Signature of patient:

Parent or guardian (if patient is a minor):

Your information will be encrypted.