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PATIENT INFORMATION

PATIENT NAME :

DATE OF BIRTH :

AGE :

SEX : Male Female

SS :

Phone No. :

Email :

HOME ADDRESS :

PRIMARY CARE DOCTOR :

PHONE:

LAST SEEN :

PHARMACY :

LOCATION :

PHONE :

WHERE DID YOU HEAR ABOUT US? :

EMERGENCY CONTACT INFORMATION

EMERGENCY CONTACT :

RELATIONSHIP :

Phone :

IS THERE A FAMILY MEMBER OR OTHER PERSON YOU WOULD LIKE FOR US TO SHARE YOUR MEDICAL INFORMATION? Yes No

INSURANCE INFORMATION

PRIMARY INSURANCE COMPANY NAME :

ADDRESS :

PHONE :

INSURED NAME :

DATE OF BIRTH :

RELATIONSHIP TO PATIENT :

EMPLOYER NAME :

POLICY :

GROUP :

SECONDARY INSURANCE COMPANY NAME :

ADDRESS :

PHONE :

INSURED NAME :

DATE OF BIRTH :

RELATIONSHIP TO PATIENT :

EMPLOYER NAME :

POLICY :

GROUP :

ALLERGIES

FOODS

TAPE

LATEX

SHELLFISH

IODINE

MEDICATIONS

ANESTHESIA

OTHER

NOT KNOWN

MEDICATIONS

PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING (INCLUDE PRESCRIPTIONS, OVER-THE-COUNTER AND HERBAL SUPPLEMENTS):

PATIENT NAME :

SURGICAL HISTORY

PLEASE LIST ALL PRIOR SURGERIES :

TYPE OF SURGERY :

DATE :

TYPE OF SURGERY :

DATE :

FAMILY HISTORY

DO YOU HAVE A FAMILY HISTORY OF :

DIABETES: TYPE 1 OR TYPE 2 CANCER THYROID DISEASE HIGH BLOOD PRESSURE STROKE CORONARY ARTERY DISEASE RHEUMATOID ARTHRITIS OTHER

CURRENT PROBLEM

DO YOU HAVE A FAMILY HISTORY OF :

WHAT SPECIFIC PROBLEM BRINGS YOU TO OUR OFFICE TODAY?

WHERE IS THE PAIN/PROBLEM LOCATED? PLEASE MARK ON THE PICTURES BELOW.

LEFT FOOT

TOP OF FOOT

BOTTOM OF FOOT

INSIDE OF FOOT

OUTSIDE OF FOOT

RIGHT FOOT

TOP OF FOOT

BOTTOM OF FOOT

INSIDE OF FOOT

OUTSIDE OF FOOT

PLEASE READ THE ACKNOWLEDGEMENT ON THE NEXT PAGE AND SIGN IT. THANK YOU.
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.

ARTHRITIS :	RHEUMATOID OSTEO GOUT OTHER
EENT :	TONSILLITIS GLAUCOMA CATARACTS EYE /VISION DIS. HEADACHES MIGRAINES HEARING DEFICIT
GASTROINTESTINAL :	ULCERS REFLUX HERNIA BOWEL DIS. IRRITABLE BOWEL SYN. HEMORRHOIDS GI BLEEDING
GENITO-URINARY :	KIDNEY OR BLADDER INFECTIONS KIDNEY STONES PROSTATE DISORDER STD
MAJOR ILLNESSES :	DIABETES TYPE I /TYPE II HYPERCHOLESTROLEMIA HYPERTENSION CHEST PAIN MI CANCER MITRAL VALVE PROLAPSE HEART MURMUR ARRHYTHMIA STROKE CHF PACEMAKER HEART DISEASE
PSYCHOLOGICAL :	ANXIETY DEPRESSION PSYCHIATRIC CONDITION DRUG OR ALCOHOL DEPENDENCY
RESPIRATORY :	ASTHMA TUBERCULOSIS EMPHYSEMA SINUS PROBLEMS SHORTNESS OF BREATH COPD LUNG DISEASE
SKIN DISORDERS :	PSORIASIS SKIN CANCER
VASCULAR DISEASE/BLOOD DISORDERS :	POOR CIRCULATION SICKLE CELL PERIPHERAL VASCULAR DISEASE LEG OR CALF PAIN NIGHT CRAMPS REST PAIN VEIN PROBLEMS SWELLING VARICOSE VEINS PHLEBITIS LEG ULCERS BLOOD CLOT DVT PE ANEMIA BLEEDING OR CLOTTING DISORDERS EASY BRUISING TRANSFUSIONS
OTHER ILLNESSES :	EPILEPSY OR SEIZURES THYROID DISEASE MUSCLE DISEASE HEPATITIS HIV OR AIDS LYME DISEASE OTHER
OTHERS:	ARE YOU PREGNANT? Yes No ARE YOU NURSING? Yes No HEIGHT : WEIGHT :

USE OF ALCOHOL :	NEVER NO LONGER USE HISTORY OF ALCOHOL ABUSE CURRENT USE -TYPE RARE OCCASIONAL MODERATE DAILY
USE OF TOBACCO :	NEVER QUIT – HOW LONG AGO? SMOKE
USE OF RECREATIONAL DRUGS :	NEVER QUIT – HOW LONG AGO? TYPE CURRENT USE -TYPE RARE OCCASIONAL DAILY
	EMPLOYER : OCCUPATION :

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