PATIENT HISTORY. Name Last First Middle/Maiden Name you Prefer. Address Street City State/Zip. Address

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1 PATIENT HISTORY GENERAL INFORMATION Name Last First Middle/Maiden Name you Prefer Address Street City State/Zip Home Phone ( ) - Cell Phone ( ) - Address Age Sex Date of Birth / / Social Security# Height Shoe Size Race Language Ethnicity Weight Married (Spouse s Name ) (Spouse s ) Single Widowed Divorced Patient s Employer: Work Phone: Work Address: Spouse s Employer: Work Phone: Work Address: RESPONSIBLE PARTY INFORMATION (If different than patient) Name: Date of Birth / / Social Security #: Address: Home Phone ( ) - Cell Phone ( ) - Employer:

2 IF ASSIGNMENT IS TAKEN, I AUTHORIZE MY INSURANCE/MEDICARE BENEFITS TO BE PAID DIRECTLY TO FOOTHILLS PODIATRY, P.A. AND AUTHORIZE RELEASE OF INFORMATION ACQUIRED IN THE COURSE OF TREATMENT IN ORDER TO PROCESS CLAIMS. I AM FINANCIALLY RESPONSIBLE FOR ALL RENDERED SERVICES. I ALSO AUTHORIZE RELEASE OF MEDICAL INFORMATION TO MY PRIMARY CARE PHYSICIAN. BY SIGNING BELOW, I AGREE TO THE ABOVE AND GRANT FOOTHILLS PODIATRY, P.A. PERMISSION FOR EVALUATION AND TREATMENT OF MY MEDICAL CONDITION. *** PAYMENT IS EXPECTED AT TIME OF SERVICE *** WE WILL FILE YOUR INSURANCE AS A COURTESY FOR YOU Date: / / Signature: PLEASE CHECK METHOD OF PAYMENT: -Cash -Check -Credit Card PLEASE GIVE RECEPTIONIST YOUR INSURANCE CARD(S). PLEASE READ AND COMPLETE ALL PAGES. THANK YOU.

3 HEALTH HISTORY Acct#: Date / / Male / Female Referred By: Name DOB / / Age Family MD: What is the reason for this visit? Location (Right or Left / Area): When did it begin? Describe pain (sharp, dull, constant, etc.): Injury? Date & Time of Injury: Anything aggravates or alleviates it? Any treatment (self or Dr.)? List all current Medications (Name & Dosage): Pharmacy Name & Location: ALLERGIES & TYPE OF REACTION: (Example: Codeine-Rash) None Penicillin Novocain Codeine Sulfa Iodine Aspirin Adhesive tape IVP Dye Anesthetics Neosporin Other Foods Latex

4 MEDICAL CONDITIONS - YOU have or had in the past. Aids (HIV) Gout Poor Circulation Currently Pregnant Alcoholism Heart Disease Rheumatic Fever Breast Feeding Anemia High blood pressure Scarlet Fever Hiatal Hernia Arthritis Kidney Disease Stroke Other: Asthma Liver DS-Hepatitis Thyroid Disorder Bleeding disorder Mental Health Tuberculosis Bowel disorder Multiple Sclerosis Ulcers Cancer Nerve Problems Varicose Veins Diabetes Phlebitis Venereal Disease Seizures/Epilepsy Polio Fibromyalgia List All Surgeries & Year: List All Serious Illness/Injuries & Year: HEALTH HABITS (USE & AMOUNT) Caffeine Tobacco Drugs Alcohol Other Occupation: Hobbies: FAMILY HISTORY: Relation Age Age of Death Cause of Death Father Mother Brother s Sister s

5 MEDICAL CONDITIONS THAT FAMILY MEMBERS HAVE: Disease Arthritis-Gout Asthma Cancer Addictions to: Diabetes Heart-Stroke High Blood Press. Kidney Disorder Tuberculosis Other: Relationship (M-mother, F-father, B-brother, S-sister) I certify that the above information is correct to the best of my knowledge. I will not hold my doctor, nurse or any members of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I also give permission to release medical records to the referring doctor insurance company or employer. Signature: Date: / / Reviewed by: Date: / / Reviewed by: CJM RAM Date: / /

6 WELCOME TO OUR PRACTICE! YOU WILL NEED TO BRING YOUR INSURANCE CARDS AND MEDICATIONS WITH YOU ON YOUR APPOINTMENT. IF YOU DO NOT HAVE THEM WE WILL NEED TO RESCHEDULE YOUR APPOINTMENT. THANK YOU!

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