SS/HIC/Patient ID #

Patient NameLast Name

First Name Middle Initial

Address

City

State Zip.

E-mail

Sex D M D F Age _ Birthdate

n Married G Widowed Q Single

O Separated Q Divorced Q Partnered for

Patient Employer/School

Minor

years

Employer/School Address

Employer/School Phone

Spouse's Name

Birthdate SS#_

Spouse's Employer.

Whom may we thank for referring you?_v;--;: nn sv mi i

Home Phone (_

Alt. Phone (

PHONE NUMBER*

J.

Best time and place to reach you.

IN CASE OF EMERGENCY, CONTACT

Name Relationship

Home Phone ( )

Alt. Phone ( )

INSURANCE

Who is responsible for this account?.

Relationship to Patient

Insurance Co.

Group #

Is patient covered by additional insurance? D Yes D No

Subscriber's Name

Birthdate_ SS#_

Relationship to Patient,

Insurance Co.

Group #

INSURANCE ASSIGNMENT AND RELEASE

I certify that I have insurance coverage with_Name of Insurance Company(ies)

and assign directly to Dr. allinsurance benefits, if any, otherwise payable to me for services rendered. Iunderstand that I am financially responsible for all charges whether or not paid byinsurance. I authorize the use of my signature on all insurance submissions.

The above-named doctor may use my health care information and may disclosesuch information to the above-named Insurance Company(ies) and their agents forthe purpose of obtaining payment for services and determining insurance benefitsor the benefits payable for related services. This consent will end when my currenttreatment plan is completed or one year from the date signed below.

MEDICARE/MEDIGAP AUTHORIZATION

I request that payment of authorized Medicare benefits and, if applicable, Medigap

benefits, be made either to me or on my behalf toName of

. for any services furnished to me by that provider.Doctor or Clinic

To the extent permitted by law, I authorize any holder of medical or other informationabout me to release to the Centers for Medicare and Medicaid Services, myMedigap insurer, and their agents any information needed to determine thesebenefits or benefits for related services.

Signature of Beneficiary, Guardian or Personal Representative

Please print name of Beneficiary, Guardian or Personal Representative

Date Relationship to Beneficiary

What is the chief complaint for which you cameto be treated? (Include foot, ankle, knee, thigh,and hip complaints.)

Have you ever been to a Podiatrist before?DYes DNo

If yes, please list.

Name

Is there any personal or family history ofdiabetes?

DYes DNo

Your occupation

Cigarette/Tobacco use.

Years smoked

Athletic activities in which you participate(please list and indicate frequency)

Last visit

Please indicate which foot problems you now haveor have had in the past.

Ankle Pain D Yes Q NoAthlete's Foot D Yes D NoBunions G Yes D NoCorns and Calluses n Yes D NoCramps or Numbness in Feet or Legs D Yes D NoFlat Feet D Yes D NoFoot or Leg Cramps D Yes D NoHeel Pain D Yes D NoIngrown Toenails DYes D NoPlantar Warts D Yes D NoSwelling in Ankles or Feet D Yes D NoTired Feet D Yes D No

MEDICAL HISTORYX^ x^^^ Place a mark on "Yes" or "No" to indicate if you have had any of the following:

L C y AIDS/HIV DYes DN° Epilepsy DYes D No Rash DYes D No^L ̂ °̂ Allergies to Anesthetics DYes D No Eye Problems DYes D No Respiratory Disease DYes D No

B Allergies to Medicine or Drugs D Yes D No Fainting D Yes D No Rheumatic Fever D Yes D No

p Anemia D Yes D No Foot or Leg Cramps D Yes D No Shortness of Breath D Yes D No

Angina DYes Q No Gout QYes Q No Sinus Problems DYes Q No

Arthritis DYes n No Headaches QYes D No Special Diet DYes D No

Artificial Heart Valves or Joints D Yes Q No Heart Disease D Yes Q No Stroke D Yes D No

Asthma DYes D No Hemophilia DYes D No Swelling in Ankles, Feet DYes D No

Back Problems D Yes D No Hepatitis or Jaundice D Yes D No Swollen Neck Glands D Yes D No

Bleeding Disorders QYes D No High Blood Pressure QYes Q No Tired Feet QYes D No

Cancer D Yes D No Kidney Problems D Yes D No Tuberculosis D Yes D No

Chemical Dependency D Yes D No Liver Disease D Yes D No Ulcers D Yes D No

Chest Pain DYes Q No Low Blood Pressure QYes Q No Varicose Veins DYes Q No

Chronic Diarrhea D Yes D No Neuropathy D Yes D No Venereal Disease D Yes D No

Circulatory Problems D Yes D No Phlebitis D Yes D No Weight Loss, unexplained D Yes D No

Diabetes D Yes D No Psychiatric Care D Yes Q No

Ear Problems D Yes D No Radiation Treatment Q Yes Q No

Surgeries you have had

Hospitalization other than for the surqeries listed

Family physician Last visit date 1

Are you now, or have you been, under any other doctor's care for any reason over the past two years? D Yes D No

If yes, please explain iI!B .-A -:-":,̂ Kk

MEDICATIONS

Include prescriptions, over-the-counter medications and vitamins

Pharmacy Name(s)

Pharmacy Phone(s) ( )

if

Do you take oral contraceptives? n Yes Q No f

Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, 1Didronel, Boniva. QYes D No 111

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include }fcombinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux •(dexfenfluramine.) n^es D No jjj

1 ALLERGIES| Q Adhesive/Tape O Local

Anesthetics

i nrsrnt nsuifa| D Aspirin D Novocaine

1 DCodeine D Penicillin1 Q Seafoods

1 Other |

m

1|

1

TREATMENT CONSENTI 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