Microsoft word - 1 pt info forms.doc

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