Patient Information Form

Patient's Name:

Patient’s Date of Birth:

Email:

Address:

City:

State:

Zip:

Mailing Address (If Different):

City:

State:

Zip:

Social Security #:

Home Phone #:

Cell Phone #:

Marital Status:

Patient (or Parent) Employed by:

Occupation:

Work Phone #:

Work Address:

City:

State:

Zip:

Person to Contact in Case of Emergency:

Name:

Phone #:

Address:

City:

State:

Zip:

How did you hear about our office?

Name of Pharmacy of Choice:

Address of Pharmacy of Choice:

City:

State:

Zip:

Insured's Name:

Insured's Date of Birth:

Primary Insurance Company:

Primary Insurance Address:

City:

State:

Zip:

Secondary Insurance Company:

Secondary Insurance Address:

City:

State:

Zip:

Medical History

Name of Family Physician:

Date last seen:

Name of Former Podiatrist:

What did your former podiatrist treat you for?

Please state your reason(s) for coming to our office?

List all medications (prescription and over the counter) that you are now using or have used in the past month:

Please give details (including the dates, hospitals, and whether you suffer any continued symptoms) of any recent hospitalization, surgery, or serious injury:

Patient's Height:

Patient's Weight:

Patient's Shoe Size:

If you checked arthritis, please specify here what type of Arthritis do you have:

If you checked allergic reaction to medication, Please list here medication(s) & reaction(s):

If you checked Tobacco use, please select one:

Past Present Past and Present

No. of packs per day:

If you checked alcohol use, please state below on how often do you use alcohol:

If you checked cancer, Please specify below what type of cancer do you have:

Please comment on any area checked above.

Family History

Please indicate the age of your parents (or the ages they were at time of death) and list any illness from above they have or had.

Father:

Mother:

Please inform us of any other important problem not covered above:

I give permission to have my prescriptions electronically retrieved through Electronic Medical Records.

I give my permission and authorize Timothy A. Quist, D.P.M. to render examination and treatment of my conditions.

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

Signature of patient or parent/guardian:

Date:

Your information will be encrypted.