New Patient Information Name: Social Security Number: Gender: Male Female Birthdate: Age: Email: Address: Phone#: House: Cell: Work: _ Primary Care Physician: Phone #: _ Date of Last Visit: Address (or Crossroads): Emergency Contact: Emergency Phone Number (other than your #): Marital Status: Single Married Separated Divorced Widowed Employment Status: Employed-Full Time Employed-Part Time t Employed Employer/School: Pharmacy Name & Location: Pharmacy Phone #: Who may we thank for referring you? Did your physician refer you?
Patient Medical History Check All that Apply: AIDS/HIV Epilepsy Polio Alcoholism Gout Rheumatic Fever Allergies Hepatitis Seizures Appendicitis Herpes Stroke Arteriosclerosis High Blood Pressure Thyroid Disorders Asthma Measles Birth Trauma Tuberculosis Cancer Type: _ Multiple Sclerosis Ulcers Chicken Pox Mumps Venereal Disease Diabetes Pacemaker Whooping Cough Emphysema Pneumonia Medical History Other Family Medical History Check All that Apply & Circle Mother (M) or Father (F): Allergy M F Emphysema M F Hypertension M F Angina M F End-Stage Renal Disease M F Melanoma M F Cancer Type: Gestational Diabetes M F Cardiovascular Disease M F Rheumatoid Arthritis M F Dementia M F Glaucoma M F Family Medical History Diabetes-Type I M F Heart Attack M F Diabetes-Type II M F High Cholesterol M F Other Social History Alcohol Use Illegal Drug Use Current Smoker Heavy Light Any History of Smoking Heavy Light How long? Alcohol, Tobacco, or Drug Use Other Surgical History Other Back Surgery Arterial Intervention Hip Replacement Foot Surgery Gall Bladder Hysterectomy Other Allergies Adhesive/Tape Demerol Nuts Anticoagulant Therapy Iodine Penicillin Aspirin Local Anesthetics Seafood Codeine vocaine Known Allergies Other Have you had your Flu Vaccine?
What is the chief complaint for which you came to be treated? Medications (please include prescriptions, over-the-counter medications and vitamins): Treatment Consent: I hereby consent and give my permission to the doctor (and the doctor s assistants or designated replacement) to administer and perform such procedures upon me as the doctor deems necessary. Signature of Patient, Parent, Guardian or Personal Representative Date Please Print name of Patient, Parent, Guardian or Personal Representative Relationship to patient Insurance Information Primary Insurance: Who is responsible for this account? Birth Date: Relationship to patient? Secondary Insurance: Who is responsible for this account? _ Birth Date: Relationship to patient? I certify that I have insurance coverage with the above and assign directly to the doctor all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The doctor may use my health care information and may disclose such information to the above-named Insurance Company (ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. Name (Print): Signature: Date:
Review of Systems- (Check all that apply) Constitutional Chills Change in appetite Dizziness Fever Nausea Thirst Weight fluctuation Vomiting Eyes Blurred vision Dry eyes Loss of vision Watering eyes Ear, se, Throat, Mouth Cough Difficulty hearing Dry mouth Runny nose Sinus congestion Tinnitus Integumentary Athletes foot Contact dermatitis Dry, scaly skin Eczema Excessive scar tissue Hypersensitivity of skin Hypertrophic scars Itchy skin Lower leg ulcers n-healing wound Psoriasis Rash Tingling sensation Musculoskeletal Bone pain Decreased range of motion Heel pain Hip pain Joint pain Joint redness Joint swelling Leg cramps Morning stiffness Muscle tenderness Muscle weakness Neurological Anesthesia Hand and feet numbness Hypersensitivity Numbness Tingling, prickling feeling Burning Genitourinary Urine Retention Painful Urination Urinary Frequency Endocrine Diabetes Decreased hair growth Increased in blood sugar Intolerance to cold Intolerance to heat Unusual fatigue Respiratory Breathing difficulty Chest pain Flu-like symptoms Shortness of breath Sleep apnea Wheezing Gastrointestinal Abdominal pain/cramping Constipation Diarrhea Heart burn Nausea Pain after eating Rectal bleeding Hematologic Allergic/immunologic symptoms Asthma attack (recent) Environmental/seasonal allergies Gout attack Cardiovascular Ankle swelling Calf cramping Chest pain Cold feet Cold hands Heart palpitations High blood pressure Loss of sensation Shortness of breath Varicose veins Pacemaker Psychiatric Addiction to alcohol Anxiousness Disoriented Memory loss
Do I Need a Test for PAD? Dear Patient, We want to make sure you are aware of a condition that may affect you. As many as 12 million Americans have Peripheral Arterial Disease (PAD) and many go dangerously unrecognized. It is a condition in which the arteries that carry blood to the muscles of the legs become narrowed due to the buildup of plaque. This is the same disease process that causes blockages of the heart. Poor circulation may result in the legs when the blood flow becomes sluggish or even blocked. It can result in leg pain or fatigue, which can limit your physical activity. Having PAD may also increase your risk of a heart attack or stroke if untreated. Please take a moment to answer the questions below so that we may briefly screen you for PAD. If you have any questions or concerns regarding PAD and your risk, or would just like more information please do not hesitate to ask. 1. Do you have a history of, or take medication for any of the following? Diabetes or borderline diabetes High Blood Pressure Smoking High Cholesterol 2. Do you have any discomfort or aching in your legs when you walk that is relieved by rest? 3. Do your legs ever feel fatigued or heavy when walking or are active? 4. Do you experience any pain at rest in your lower leg(s) or feet? 5. Are you bothered at night with burning, pain, or coldness in your feet or toes? 6. Do you ever need to stop and rest when walking or have difficulty keeping up with others? 7. Have you noticed any changes in the color or temperature of your feet? 8. Have you experienced poor healing of wounds or ulcers on your feet? Patient Signature: Physician Signature: Date: Date: tes:
NOTICE OF PRIVACY PRACTICES Federal and State HIPAA laws require that after April 14, 2003 all patients are informed of their podiatric office s particular privacy practices. We have instituted various safeguards and practices to protect your personal health information and we especially focus on keeping confidential any information that you may consider sensitive. In compliance with the HIPAA laws, we are providing you with a formal notice of our privacy practices. This notice is also posted in our reception area. In the normal process of our daily operations we do need to disclose some information: 1. To remind you of upcoming appointments, we may mail reminder cards or call and leave a message stating the time and date of your appointment. 2. To process your insurance claims, we must tell your insurance company what treatment was done and the date of service. 3. We may call to inform you of tests/lab results. 4. We need to send statements to you. 5. For treatment, we may disclose your personal health information to physicians, nurses, and other health care personnel who provide you with health care services or are involved in your care. I request that all communication to me by Dr. be done with the following phone number and address. Phone Number: Home Cell Other May we leave a message? YES NO List those people we may leave a message with or speak with concerning your personal health information: Address: I have read this notice and was offered/received a copy from the office. Signature of Patient/Guardian: Date: For Office Use Only Accept _ Deny _ Privacy Office Initials: Date: