Patient Information Form

Date:

First Name:

MI:

Last Name:

Address:

Apt #:

PO Box:

City:

State:

Zip:

Home Phone #:

Cell Phone #:

Work Phone #:

Email address:

Birthdate:

Age:

Gender:

M F

Social Security #:

Marital status:

Married Partner Single Widowed Separated

Employment status:

Full time Part time Not employed

Employer:

Spouse’s name:

Spouse's phone number:

Spouse’s Birthdate:

Spouse’s Social Security #:

If you are a student or minor, who is the responsible party?

What is their address?

How did you choose our office?

Friend/Family Physician referral Internet Phone book

Who is your primary physician?

Date last seen:

If you were referred by a physician, whom?

How would you prefer we contact you?

Home Phone

Cell Phone

Work Phone

E-mail

Text

Emergency contact:

Phone:

Relationship:

Insurance

Name of insured:

Same

Birthdate of insured:

Same

Address of insured:

Same

Phone of insured:

Same

Name of primary insurance company:

Subscriber #:

Group #:

Name of secondary insurance company:

Subscriber #:

Group #:

Name of tertiary insurance company:

Subscriber #:

Group #:

Are you seeing us for a work-related injury?

Yes No

Are you seeing us for an injury related to a car accident or injury on a person’s property?

Yes No

If yes, please explain:

I hereby assign my insurance benefits to be paid directly to Council Bluffs Foot & Ankle Care.
I also authorize the physician to release any information requested by my insurance company.
I understand that the above information concerning my condition will be used for filing insurance reports.
I certify all the information to be true and complete.
I have read Council Bluffs Foot & Ankle Care's financial policy and agree with it's terms.
I understand I am financially responsible for all charges not covered by my insurance company.

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:

Date:

History Form

Name:

Date:

Height:

Weight:

Shoe Size:

Pharmacy:

Pharmacy's Location:

Describe the main problem(s) for which you would like treatment (indicate left or right):

How would you describe your pain or condition?

How would you rate your pain?

No pain Mild Moderate Severe

1-10 Scale:

How long has this problem been going on?

Is the problem:

Improving Staying the same Worsening

Describe what makes the pain/problem better:

Describe what makes the pain/problem worse:

Describe anything that has been done for treatment:

List the medications that you are taking (include OTC meds and supplements)

Medication:

Add more:

Do you have any allergies?

Yes No known allergies

Other:

If yes, please list:

Allergy:

Add more:

List your past surgeries:

Surgery:

Add more

Review of Systems

Past Medical History

If Other, please specify:

Family History

If applicable, check which family member has the following conditions:

Diabetes:

No history

Mother

Father

Sister

Brother

Other:

Cancer:

No history

Mother

Father

Sister

Brother

Other:

Heart disease:

No history

Mother

Father

Sister

Brother

Other:

Kidney disease:

No history

Mother

Father

Sister

Brother

Other:

Liver disease:

No history

Mother

Father

Sister

Brother

Other:

Lung disease:

No history

Mother

Father

Sister

Brother

Other:

Social History

Smoking status:

Non-smoker Former smoker Current smoker

Alcohol use:

None Occasional Daily

Drug use:

No Yes

# Caffeinated beverages/day:

Pregnant?

No Yes

Number of weeks pregnant:

Exercise:

None Some Daily

Occupation:

# hours on feet/day:

Your information will be encrypted.

Patient Information Form

Insurance

History Form

Review of Systems

Past Medical History

Family History

Social History

Council Bluffs Foot & Ankle Care