New Patient Forms

Practice:

Today's Date:

Name:

DOB:

Chart Number:

Sex:

M F

Marital Status:

Single Married Widowed Divorced

SS#

E-mail:

E-mail newsletters, reminders, statements, etc

Spouse/PartnerName:

Emergency Name:

Phone:

Address:

City:

State:

Zip:

Home #:

Cell #:

Other #:

Employer:

Phone:

Employer Address:

City:

State:

Zip:

Primary Insurance:

Are you the insured?

Yes No

Insured Information

Subscriber Name:

Relationship to insured:

Spouse Child Self Other

Phone #:

Sex:

Male Female

DOB:

Address:

Policy ID:

Group ID:

Employer:

Secondary Insurance:

Are you the insured?

Yes No

Insured Information

Subscriber Name:

Relationship to insured:

Spouse Child Self Other

Phone #:

Sex:

Male Female

DOB:

Address:

Policy ID:

Group ID:

Employer:

How did you find out about our practice?

Physician Internet Telephone Book Friend Family Member Other

Other:

What is the reason for your visit today?

Result of accident or work injury?

Yes No

How long has this bothered you?

1 2 3 4 5 6 7

Days Weeks Months Years

What treatments have you tried & have they been effective?

On a scale of 1 -10 (I being no pain and I 0 being the worst) what is you r level of pain?

The pain quality is:

Burning

Constant

Dull

Sharp

Shooting

Throbbing

Tingling

Other:

PLEASE READ AND SIGN

The above information is correct to the best of my knowledge. I u nderstand that throughout my treatment, I am responsible for notifyingthe physician and/or medicalstaff of anyand all u pdatestothe information listed above.

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

Patient Signature:

Date

History and Physical

Name:

DOB:

Chart Number:

Neuropathy

(specify)

Thyroid disease

(specify)

Arthritis

(specify)

Diabetes (type I,type 2)

(specify)

Other

Are you pregnant?

Yes No

Are you nursing?

Yes No

Surgical History

None

Appendectomy

C-Section

Angioplasty

Bypass

Cataracts

Cholecystectomy

Have you ever had any surgical procedures on foot/ankle or anywhere else on your body

Yes No

If yes, please describe:

Do you have any artificial joints?

Yes No

(Where?)

Do you have an artificial heart valve?

Yes No

Social History

Do you smoke?

Yes No

If yes how many packs per day?

1 2 3 4 5

For how long?

Do you drink alcohol?

Yes everyday (5-7 days/week) Yes, occasionally/socially No/Rarely

Substance abuse

Yes, I have a current substance abuse problem.

Please Specify

Yes, I had a past substance abuse problem.

Please Specify

No, I have never had a substance abuse problem

What is you r occupation?

Does it involve mostly

Standing Sitting

Do you exercise regularly?

No, I do not exercise regularly Yes, I do the following regular exercise:

Family History

Is there any family history(blood relative) of:(Please indicate family member)

Alzheimer's

Depression

Arthritis

Diabetes

Bleeding disorders

Emphysema

Blood clot

Heart Disease

Cancer

High Blood Pressure

Cataracts

Neurological

Circulation problems

Storkes

Review of Systems (Please check the box if you currently have any of these symptoms or check "NONE")

Genitourinary

blood in urine

decreased frequency

hesitancy

excessive urination

incontinence

kidney disease

increased urgency

kidney stones

NONE

lntegumentary

athletes foot

nail abnormalities

keloids

itchiness

dry, scaly skin

NONE

Hematologic

lower leg ulcers

sickle cell disease

anemia

blood thinners

clotting disorder

NONE

Neurological

tingling

tremors

weakness

paralysis

seizures

numbness

headaches

NONE

Respiratory

chest pain

shortness of breath

wheezing

emphysema

COPD

coughing

snoring

NONE

PLEASE READ AND SIGN

The above information is correct to the best of my knowledge. I understand that throughout my treatment, I am responsi ble for notifying the physician and/or medical staff of any and all updates to the information listed above.

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

Patient Signature:

Date:

Practice:

Today's Date:

Name:

Chart #:

Date of birth:

Ethnicity:

Hispanic or Latino Not Hispanic or Latino Declined to specify

Race:

Asian White American Indian or Alaska Native Native Hawaiian or other Pacific Islander Black or African American Declined to specify

Preferred Language:

Declined to specify

Pharmacy Name:

Pharmacy Phone:

Pharmacy Address:

City, State, Zip:

Primary Care Physician:

Phone:

Date Last Seen

Address:

Referring Physician:

Phone:

Date Last Seen

Address:

Privacy Information Preferences

Do you want to be exempt from public reporting?

Yes No

Can we send mail to the address on file?

Yes No

Can we call the phone number on file?

Yes No

Can we leave voicemail on machine?

Yes No

Will you allow usto send internet based (e-mail) delivery of reminders and newsletters?

Yes No

If yes, please provide your e-mail address:

Who can we leave messages with?

Wife

Husband

Daughter

Son

Other:

Name(s):

Smoking Status

Checkbox list

Current Every Day

Smoker, Current Status Unknown

Current Some Day

Heavy Tobacco

Unknown If Ever

Former

Never

Light Tobacco

Decline to answer

Vital Signs

Blood Pressure:

Height:

Weight:

Current Medications

No Known Medications I take the following medications

Add new row

Allergies

No Known Allergies No Known Drug Allergies

Add new row

Last Flu Shot Date:

Did you get a pneumococcal vaccination?

Yes No

Have you fallen in the last 1 2 months?

Yes No

Were you injured from the fall?

Yes No

Advanced Directives:

Living Will DNR Durable Power of Attorney Surrogate Appointed None

PLEASE READ AN D SIGN: The information on my intake form(s) is correct to the best of my knowledge. I understand that throughout my treatment, I am responsi ble for notifying the physician and/or medical staff of any and all updates to the information listed above. (Assignment of Benefits): I authorize payment of medical benefits to the practice named above. (Release of Information): I authorize the release of any medical information necessary to process this claim. (Hf PAA Privacy): I acknowledge that I received my HIPAA Privacy Pr·actices Notice. (Medication Histo1y): I authorize the Doctor's office to retrieve my medication history

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

Patient Signature:

Date:

COMPREHENSIVE PODIATRY ASSOCIATES, P.C.

Practice Policies and Financial Agreement

As a patient of Comprehensive Podiatry Associates, Iunderstand and agree that:

My appointment time is reserved for only me. Iwill be responsible for cancelling any appointment 24 hours in advance. Iunderstand that the office will attempt to confirm my appointment in advance, but ultimately it is my responsibility to keep this appointment. I am aware that the office will charge a $50 fee for any missed appointment.
Payment for services is expected when services are rendered. Imay pay with cash, check or credit card. There is a $30 fee added for all checks returned for insufficient funds. Your insurance requires us to collect the copay at the time of service.
Iam aware that any changes regarding my address, phone number or insurance information must be communicated immediately to the staff so that my account is up to date and the correct information can be billed to my insurance company.
It is my responsibility to understand the coverage, benefits and limitations of my insurance plan. Iam aware that Iwill be responsible for anything my insurance company deems a "non-covered service."
It is my responsibility to ·know if my insurance requires a referral for my visit, and it is my responsibility to secure that referral prior to the visit. If my insurance requires a referral and Ido not have one at the time of visit, Iunderstand that Iwill be responsible for the full cost of the visit.
Any balance on my account left unpaid for more than 90 days will go into collection status and it will be forwarded to an outside collection agency. I understand that I will be responsible for the additional 33°/o collection cost and for any additional costs of collecting, including attorney fees, legal fees and interest accrued.
If I have no insurance coverage, I am a self-pay patient. Payment is expected at the time of service.
I am aware that if I have a no copay plan with a deductible, I am responsible for paying any costs incurred during my visit that my insurance company deems "Patient Responsibility".

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

Name:

DOB

Signature:

Date

Your information will be encrypted.