New Patient Information

Emergency Assistance

If this is an emergency, call 911.

Patient Information

First name

Last name

Social Security Number

If you do not provide your social security number, you are required to provide (2) forms of photo ID at your visit.

Age of Patient

Date of birth

If you do not provide your social security number as proof of identification, then you are required to provide (2) forms of photo identification at the time of your visit. Please sign below acknowledging this policy.

Contact Information

Street Address

Apartment #

City

State

Zip Code

Cell phone number

Home Phone Number

Email address

Emergency Contact Information

Add another emergency contact

Patient Demographic Information

How did you find our office?

A friend/family member referred me My primary doctor referred me Another doctor beside my primary doctor referred me Facebook Instagram Zocdoc

What is your ethnicity?

Race Choose an option below that best describes your race.

American Indian Alaska Native Asian Black or African American Native Hawaiian White Hispanic Other

Do you have a legal guardian or healthcare power of attorney? Yes/No.

If you have a legal guardian or healthcare power of attorney, what is their name and phone number?

Do you have an advance directive (living will)? Yes/No

Pharmacy Information

Do you give permission for us to access your prescription history?

Yes No

Pharmacy Information

CVS Walgreens Safeway Giant Other

Pharmacy Address

Insurance Information

Do you have health insurance?

Yes No, I am a self-pay patient.

Primary Health Insurance Name

Please provide primary insurance name above.

What is your primary insurance policy number or member ID?

Do you have a secondary insurance?

Yes No

What is the secondary insurance's name?

What is your secondary insurance policy number or member ID?

What is your Primary Care Provider (main doctor's) name?

What is your Primary Care Provider (main doctor's) office telephone number?

What is your Primary Care Provider (main doctor's) fax number?

Date you last saw your primary care provider:

Social History Information

How often do you use alcohol?

Never Daily Occasionally 1-2 times/week

How often do you use tobacco?

Never Daily Occasionally

How often do you use recreational drugs?

Never Daily Occasionally

How much are you on your feet during the day?

10% 25% 50% 75% 100%

How often do you exercise?

Never Occasionally Daily

Medical History Information

Please list other medical conditions not mentioned above:

Please list all allergies to medication or food (do not include seasonal allergies). If you do not have allergies, please type "no allergies".

Please list the medications you are taking and for what conditions. Include the dosage and amounts.

Please list all prior surgeries with the date of surgery.

Do you have a family history of diabetes, cancer, heart disease, high blood pressure, stroke, or rheumatoid arthritis?

Yes No

Reason For This Visit

What problem would you like to discuss with Dr. Sadoughi?

Where is the pain/problem located?

How long ago did the pain/problem begin? (days, weeks, months)

How would you describe your pain?

No pain

Sharp

Dull

Aching

Burning

Radiating

Itching

Stabbing

Since your pain or problem began, has it:

Stayed the same Become Worse Improved

What makes the pain or problem better?

Rest Ice Wrapping with bandage Medication such as (tylenol, advil) refraining from high intensity activity Something else

Was this problem caused by an injury?

Yes No

When did this injury occur?

Patient Consent for Treatment

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.

Please Type Your Name Below (this acts as an e-signature)

HIPAA Acknowledgement

I understand a copy of the HIPAA Privacy Practice is available to me upon request.

Please Type Your Name Below (this acts as an e-signature)

Your information will be encrypted.

Dr. Navid Sadoughi, DPM AACFAS

Doctor of Podiatric Medicine, Chevy Chase Foot and Ankle LLC

Dr. Sadoughi is a graduate of the University of Maryland and Temple University. He is board qualified by the prestigious American Board of Foot and Ankle Surgery in both foot and reconstructive rearfoot and ankle surgery. He has a comprehensive approach towards his patients and he believes in exhausting all the conservative methods before an invasive surgical procedure is performed. We look forward to your visit and welcoming you to Chevy Chase Foot and Ankle!