Patient Intake Form

Patient Information

First Name:

Last Name:

Date of Birth:

Social Security #:

Email Address:

Address (Home):

City:

State

Zip Code:

Phone (Mobile):

Phone (Home):

Employer Name:

Employer Phone Number:

Emergency Contact

First Name:

Last Name:

Phone:

Relationship:

Phone Type:

Home Mobile Work Other

Insurance Information

Do You Have Insurance?

Yes No (Skip to Complaint Summary Section)

Policy Holder

First Name:

Last Name:

Date of Birth:

Phone (Mobile):

Phone (Home):

Home Address:

City:

State:

Zip Code:

Insurance Company Name:

Policy ID/#:

Policy Group ID/#:

Social Security #:

Insurance Plan (i.e. HMO, PPO, etc.):

Relationship to Patient:

Do you Have Medical Coverage?

Employer Name (Policy Holder):

Employer Phone (Policy Holder):

Responsible Party Information

Relationship to Patient:

Self (Skip to next section) Spouse Parent Other

First Name:

Last Name:

Date of Birth:

Social Security #:

Address:

City:

State:

Zip Code:

Phone (Mobile):

Phone (Home):

Employer Name:

Employer Phone:

Complaint Summary:

Describe Complaint:

How and When Did it Begin?

If Other Chosen Above, Please Explain Below:

Frequency of Complaint

Intermittent

Occasional

Frequent

Constant

If Other Chosen Above, Please Explain Below:

List Daily Activities Most Affected by this Complaint:

List Any Treatment You Have Received for This Complaint:

Have You Taken Any Medications?

Yes No

If You Answered ‘Yes’ Above, Please List What You Have Taken (Prescriptions or OTC):

Have You Had Any Diagnostic Testing Performed for Above Complaint?

X-Ray(s)

CT Scan

MRI

Other

No Tests Have Been Performed

If Other Chosen Above, Please Explain Below:

Health Summary

Please List Current Medications Including How Often and Dosage

Any Allergies to Any Medications (List Below):

Relevant Major Health Problems in Your Immediate Family:

List Any Major Surgeries Received and Date:

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Patient Intake Form

Patient Information

Emergency Contact

Insurance Information

Policy Holder

Responsible Party Information

Complaint Summary:

Health Summary

Mohan Mensah, DPM