MOBILE PODIATRY PATIENT INTAKE FORM

Today's Date:

Patient Name:

DOB:

Age:

Home Address:

City:

State:

Zip:

Home Phone:

May we leave a message?

Yes No

Cell Phone:

May we leave a message?

Yes No

E-mail

Primary Language:

Do you have a legal guardian or power of attorney?

Yes No

If yes, Please provide legal documentation

Emergency Contact:

Phone:

Primary Care Doctor:

Pharmacy:

Phone:

Who is responsible for payment?

Insurance Information

Primary Insurance:

Member ID:

Secondary Insurance:

Member ID:

Your Medical History

Do you have any allergies to any of the following?

Medications

Anesthesia

Tape

Latex

Iodine

Other

No Known Drug Allergies

Please list all medications you are allergic to:

Add Allergies

Please list all medications you are currently taking:

Add Medications

Have you eve been diagnosed with the following:

Diagnosis Notes

Current Problem

What specific problem brings you to our office today?

How long ago did this problem start?

Days Weeks Months Years

Did you pain or problem begin:

All of a sudden Gradually develop over time

How would you describe your pain?

No pain

Sharp

Dull

Aching

Burning

Radiating

Itching

Stabbing

Since the time your pain or problem began, has it

Stay the same Become worse Improved

What makes your pain or problem feel worse?

Improved Walking Standing Daily activities Resting Dress shoes High heels Flat shoes Close toe shoes

What makes your pain or problem feel better?

What treatments have you had for this problem?

How has this problem affected your lifestyle or ability to work?

Was this problem caused by an injury?

Yes No

Please describe

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 charges in my medical status.

Print Name of patient

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Signature of patient

Date:

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