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Midtown Foot Clinic, PC & Midtown Surgical Center, LLC
PATIENT INFORMATION
Name:___________________________________________________Soc. Sec. #:_____________________ Last Name First Name Initial Address:________________________________________________________________________________ City:______________________________________ State:_______________________ Zip:______________ Home Phone:___________________ Cel Phone:_________________ Work Phone:_________________ Email Address:_____________________________________ Date of Birth:___________________ Sex: [] M [] F Age:______ Marital Status: [] Single [] Married [] Widowed [] Other Ethnic Group: [] Hispanic or Latino [] Not Hispanic or Latino [] Decline Information Race: [] American Indian or Alaska Native [] Asian [] African American [] Caucasian [] Native Hawai an or Other Pacific Islands [] Other Race [] Decline Information Preferred Language: ___________________ Family Physician:__________________________ Whom may we thank for referring you?____________________________ Patient Employed by:________________________________ Occupation:_____________________ Business Address:______________________________ Business Phone:______________________ In case of an emergency, contact:________________________ Home Phone:__________________ Relationship to patient:________________________________ Work Phone:___________________ In case of an emergency, contact:________________________ Home Phone:__________________ Relationship to patient:________________________________ Work Phone:___________________ Patient______________________________________________________________ INSURANCE INFORMATION
Do you have Medicare [] Yes [] No If Yes, ID #_______________________________________ Do you have Medicaid [] Yes [] No If Yes, ID #_______________________________________ Primary Insurance Co._____________________________________ Phone:_________________________ Policy / Subscriber #:_____________________________ Group #:___________________________ Address:_______________________________ City/State:_____________________ Zip:_________ Insured Name:_________________________________________________________________________ Social Security # of Insured :______________________ Insured Date of Birth __________________ Relationship to Patient:____________________ Insured Employed By:________________________ Secondary Insurance Co.___________________________________ Phone:________________________ Policy / Subscriber #:_____________________________ Group #:___________________________ Address:_______________________________ City/State:_____________________ Zip:________ Insured Name:_________________________________________________________________________ Social Security # of Insured :______________________ Insured Date of Birth __________________ Relationship to Patient:____________________ Insured Employed By:________________________ Person responsible for payment, if other then patient: ____________________________________________________________ Phone #____________________ Last Name First Name Initial
Address:__________________________________ City/State:________________________ Zip:__________
Patient______________________________________________________________ MEDICAL HISTORY & INFORMATION
Shoe Size:______________ Weight:______________ Height:______________ Do you have Heart Valve Implants? [] Yes [] No Do you have any artificial joints or limbs? Hip, [] Yes [] No Knee, [] Yes [] No Other:_________________ Please circle if you have or have had any of the fol owing:Anemia Please circle or list al ergies or sensitivities:Adhesive Tape Patient______________________________________________________________ Mother: [] Living [] Deceased [] Cause of death:___________________________________ Father: [] Living [] Deceased [] Cause of death:___________________________________ Brother(s): [] Living [] Deceased [] Cause of death:___________________________________ Sister(s): [] Living [] Deceased [] Cause of death:___________________________________ Please circle if there is a family history of:Arthritis Do you smoke? [] No [] Yes, how long?_____________ Number of pack(s) per day?____________ Did you previously smoke? [] No [] Yes, for how long and number of pack(s) per day?_____ / ______ Do you drink alcohol or beer? [] No [] Yes, usage: [] Light (1-2 per week) [] Moderate (1-2 per day) [] Heavy (2+ per day) Employment: Do you? [] Sit at job [] Stand at job [] Stand and walk at job [] Retired What problems bring you to our office? ________________________________________________________________________________________ ________________________________________________________________________________________ How long have you had these problems? _______________________________________________ Have you had any past surgical procedures on your feet or ankles? [] No [] Yes If yes, what was done and when ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

Source: http://midtownfootclinic.net/Patient-Info.pdf

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Chapter 8 What would you do if you realized you had become addicted to marijuana?After reading the following statements, respond to each one by writing yes or no. 1. The use of illegal drugs on college campuses in the United States is widespread. 2. I have never experimented with illegal drugs (marijuana, cocaine, heroin, LSD). 3. The use of marijuana should be legalized. 4. Cocaine

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