LAWRENCE by jennyyingdi

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									                                        LAWRENCE J. KALES, D.P.M., P.A.                                        DATE: ______________________
□ Bayonet Point Foot Health Center                                                             □ Spring Hill Podiatry Center
We apologize for any inconvenience this forms causes you. Due to evolving government requirements and the ability to interact with your primary
                                         healthcare provider, we are required to obtain this information.

PATIENT INFORMATION
Patient's Name: ______________________________________________________________________________________________________________________________
                            First                                      Middle                                Last
Address: ______________________________________________________________________________________________________________________________________

City: ________________________________________________________________________ State: ___________________ Zip Code: ____________________________

Home Phone #: (            ) _______________________________________             Work/Cell #: (          ) ______________________________________

Social Security #: __________-__________-__________ Birth date: ________/________/________ Age: ____________ Sex:  Male  Female

Can we leave a message on your machine? Yes No

Race:    White Black Hispanic Asia American Indian Other: ______________________________________________________

Ethnicity: ___________________________________________________________________  Refused/Does not know

E-mail Address: ____________________________________________________________                 I authorize e-mail contact:         Yes  No

Who can we leave a message with or discuss medical condition including diagnosis, treatment, payment and
healthcare with?
Name: __________________________________________________________ Relation Spouse  Daughter  Son Other: ________________________

Emergency Contact: ______________________________________________________            Phone #: (         ) ________________________________________
                                    Name/Relation
INSURANCE INFORMATION
Primary Health Plan Name: _______________________________________________________________________ Effective Date: ______________________

Insured Name: ______________________________________________________________________________________ Policy #: _____________________________

Date of Birth: ________/________/________ Age: ___________ Last 4 SS#: ________________ Employer: ______________________________________

Secondary Insurance Name _______________________________________________________________________ Effective Date: ______________________

Insured Name : ______________________________________________________________________________________ Policy #: _____________________________

Date of Birth: ________/________/________ Age: ___________ Last 4 SS#: ________________ Employer: ______________________________________

RESPONSIBLE PARTY INFORMATION
Relationship to Patient: ___________________________________________________________________________________________________________________

Name: _________________________________________________________________________________________________________________________________________
                            First                                      Middle                                Last
Address: ______________________________________________________________________________________________________________________________________

City: ________________________________________________________________________ State: ___________________ Zip Code: ____________________________

Home Phone #: (            ) _______________________________________            Work/Cell #: (          ) ______________________________________

Social Security #: __________-__________-__________ Birth date: ________/________/________ Age: ____________ Sex:  Male  Female

Height _________________ Weight _________________ Last Blood Pressure Reading _________/_________  Shoe Size ______________
How did you hear about us? _____________________________ Do you wish to be exempt from reporting* functions?  Yes  No
                                                                         * Insurance Diagnosis and Medical Reporting
Have any of your family members been seen in our office before:  Y  N Name: _______________________________________________
Name of Primary Physician: _____________________________ Phone #: (                ) _____________________ Last visit date:______/_______/______
What specific problem(s) bring you to our office today? __________________________________________________
How long ago did this problem first start?  Days             Weeks            Months           Years
Did your pain or problem:              Start all of a sudden                  Gradually develop over time

How would you describe your pain?  No pain  Sharp              Dull  Aching  Burning  Radiating  Itching
                                   Stabbing                     Other ________________________
How would you rate your pain on a scale of 1 to 10 (Please Circle)
            (No Pain)    0    1    2     3     4    5    6     7           8      9    10    (Worst Pain Possible)
Location: Please indicate where you are experiencing pain
          Right:  Foot       Ankle          Toe  Heel
          Left:  Foot        Ankle          Toe  Heel
Since the time your pain or problem has begun, has it:           Gotten Better          Worsened            Stayed the same
Does the following make your pain or problem feel worse?
Morning  Night  Applying weight walking/standing  Daily Activities  Resting Exercising                           Dress Shoes
 High Heels        Flat Shoes        Closed Shoe     Other: __________________________
Does anything make the problem or pain better?  Yes  No What? ___________________________________________
Is this pain/problem the result of an injury? Yes  No What happened? ___________________________________
If yes, was it work related? Yes  No What happened? _________________________________________________________
Have you ever been treated by a foot specialist?  Yes  No          When __________________________________________
Do you ever get cramps, tightening of the muscles or burning in legs?  Yes            No     Sometimes


Medical History         * ARE YOU BEING TREATED FOR OR HAVE BEEN TREATED FOR ANY OF THE FOLLOWING?

  Yes  No    AIDS/HIV                       Yes  No    GOUT                            Yes  No    POOR CIRCULATION
  Yes  No    ALCOHOLISM                     Yes  No    HEART ATTACK                    Yes  No    RHEUMATIC FEVER
  Yes  No    ANEMIA                         Yes  No    HEARTBURN/REFLUX                Yes  No    SEXUALLY TRAN. DIS.
  Yes  No    ARTHRITIS                      Yes  No    HEART PROBLEMS                  Yes  No    SICKLE CELL
  Yes  No    ASTHMA/COPD                    Yes  No    HEPATITIS ___A ___B ___C        Yes  No    SKIN DISORDERS
  Yes  No    BLEEDING PROBLEMS              Yes  No    HIGH BLOOD PRESSURE             Yes  No    STOMACH ULCER
  Yes  No    BRONCHITIS/EMPHYS.             Yes  No    JOINT IMPLANTS                  Yes  No    STROKE
  Yes  No    BURSITIS                       Yes  No    KIDNEY PROBLEMS                 Yes  No    THROMOPHLEBITIS
  Yes  No    CANCER; TYPE:___________       Yes  No    LEUKEMIA                        Yes  No    THYROID DISEASE
  Yes  No    CHOLESTEROL                    Yes  No    LIVER PROBLEMS                  Yes  No    TUBERCULOSIS
  Yes  No    COLOTIS/CRON’S DIS.            Yes  No    LUNG DISEASE                    Yes  No    TUMORS
  Yes  No    DIABETES **                    Yes  No    MENTAL DISORDERS                Yes  No    _____________________________
  Yes  No    DRUG ABUSE                     Yes  No    MITRAL VALVE PROLAP             Yes  No    _____________________________
  Yes  No    EPILEPSY/SEIZURE               Yes  No    NERVE CONDITIONS                Yes  No _____________________________
  Yes  No    GLAUCOMA                       Yes  No    OSTEOPOROSIS                    Yes  No    _____________________________

Please list any Previous Hospitalizations/Surgeries/Serious Illness and when:
     _________________________________________________________  _________________________________________________________________
     _________________________________________________________  _________________________________________________________________
     _________________________________________________________  _________________________________________________________________
     _________________________________________________________  _________________________________________________________________
     _________________________________________________________  _________________________________________________________________
PHARMACY INFORMATION
Pharmacy Name: ___________________________________________________________ Phone # ( ) ______________________________________
Address: __________________________________________________________________________________

Do you take medication on a daily basis, including pills, injectables, or herbs?  Yes  No  See attached list
 Medication Name:                                                                Dosage:
 Medication Name:                                                                Dosage:
 Medication Name:                                                                Dosage:
 Medication Name:                                                                Dosage:
 Medication Name:                                                                Dosage:
 Medication Name:                                                                Dosage:
 Medication Name:                                                                Dosage:
 Medication Name:                                                                Dosage:
 Medication Name:                                                                Dosage:
 Medication Name:                                                                Dosage:

I authorize Dr. Kales to download my medication history and Rx benefits into my account from an Rx clearinghouse.
_____________________________________________________________________           ____________________________
Patient Signature                                                                Date

Social History
Marital Status:  Single  Married  Partnered Separated Divorced Widowed  Live Alone Y N

Use of Alcohol:  Never  No Longer Use           History of Alcohol Abuse
        Current Use: Type _________________________     Rare Occasional Moderate Daily

Use of Tobacco: Never Quit How Long Ago? ______________________ Type _________________________
        Current Use: Type _________________________ # Packs Per Day___________  Rare Occasional Moderate Daily

Do you have a history of substance abuse? Yes No If yes, what substance(s)? _____________________________

Exercise: Never Rare Occasional Weekly Several times a week Daily
        Types of exercise ____________________________________________________________________________

Family History
 Do you have a family history of the following?
Arthritis:       Mother  Father Grandmother Grandfather                    Brother Sister      Aunt Uncle   Cousin  Family
Bleeding         Mother  Father Grandmother Grandfather                    Brother Sister      Aunt Uncle   Cousin  Family
Disorders:
Cancer:          Mother  Father Grandmother Grandfather                    Brother Sister      Aunt Uncle   Cousin  Family
Circulatory      Mother  Father Grandmother Grandfather                    Brother Sister      Aunt Uncle   Cousin  Family
Disease:
Diabetes:        Mother  Father Grandmother Grandfather                    Brother Sister      Aunt Uncle   Cousin    Family
Foot Problems: Mother  Father Grandmother Grandfather                      Brother Sister      Aunt Uncle   Cousin    Family
Heart Disease: Mother  Father Grandmother Grandfather                      Brother Sister      Aunt Uncle   Cousin    Family
High Blood       Mother  Father Grandmother Grandfather                    Brother Sister      Aunt Uncle   Cousin    Family
Pressure:
Kidney           Mother  Father Grandmother Grandfather                    Brother Sister      Aunt Uncle   Cousin  Family
Disease:
Mental Illness: Mother  Father Grandmother Grandfather                     Brother Sister      Aunt Uncle   Cousin  Family
Neurological     Mother  Father Grandmother Grandfather                    Brother Sister      Aunt Uncle   Cousin  Family
Problems:
Rheumatoid       Mother  Father Grandmother Grandfather                    Brother Sister      Aunt Uncle   Cousin  Family
Arthritis:
Skin Disease:    Mother  Father Grandmother Grandfather                    Brother Sister      Aunt Uncle   Cousin  Family
Stroke:          Mother  Father Grandmother Grandfather                    Brother Sister      Aunt Uncle   Cousin  Family
Thyroid          Mother  Father Grandmother Grandfather                    Brother Sister      Aunt Uncle   Cousin  Family
Disease:
REVIEW OF SYSTEMS: * PLEASE CHECK THE BOX IF YOU ARE EXPERIENCING THE FOLLOWING:
 Cardiovascular                   Eyes                       Gynecologic                  Neurological
 Calf pain with                   Blindness                  Absence of period not in     Confusion
exercise/sleeping                  Blurred/ double vision    menopause                      Convulsions or seizure
 Chest pain or angina             Cataracts                  Irregular painful period     Fainting
 Congestive Heart Failure         Eye disease or injury      Vaginal discharge            Frequent recurring
 Heart Attack                     Wear glasses/contact      # of pregnancies _________    headache
 Heart trouble                   lenses                      # of miscarriages _________    Head injury
 Murmurs                                                                                    Insomnia
 Palpitation                                                                                Light headed or dizzy
 Shortness of breath                                                                        Migraines
 Swelling of feet ankles or                                                                 Nervous Disorder
hands                                                                                        Neuropathy (loss of
                                                                                            sensation)
                                                                                             Numbness tingling
                                                                                             Paralysis or weakness
                                                                                             Poor Balance
                                                                                             Speech Difficulty
                                                                                             Tremors
   Constitutional Symptoms        Gastrointestinal             Hematological              Psychiatric
                                   Abdominal pain                Lymphatic
 Chills                           Change in bowel            Anemia                       Depression
 Fever                           movements                    Bleeding or bruising         Insomnia
 Fatigue                          Frequent diarrhea         tendency                       Memory loss or confusion
 Good general health lately       Loss of appetite           Enlarged glands              Nervousness
 Recent weight gain or loss       Nausea or vomiting         Past transfusions            Tension
 Sweats                           Painful BM or              Phlebitis
                                  constipation                 Slow to heal after cuts
                                   Rectal bleeding/ blood
                                  in stool
                                   Weight gain or loss
   Ears/Nose/                     Genitourinary              Integumentary                  Respiratory
    Mouth/Throat                   Blood in urine             Birth Mark
 Hearing loss or ringing          Burning or painful         Breast discharge             Chronic Frequent cough
 Earaches or drainage            urination                    Breast lump                  Difficulty breathing
 Sinus problems                   Change in force or         Breast pain                  Shortness of breath
 Nose bleeds                     strain when urinating        Change in hair or nails      Spitting up blood
 Mouth sores                      Discharge from penis or    Change in skin color         Wheezing
 Bleeding gums                   vagina                       Eczema
 Bad breath or bad taste          Incontinence or            Growth on skin
 Difficulty swallowing           dribbling                    Hair loss
 Chronic tonsillitis              Kidney stones              Lesions
 Laryngitis                       Males: testicular pain     Piercing
 Sore throat or voice change      Sexual difficulty          Rash or itching
 Swollen glands in the neck                                   Recurring infections
                                                               Sensitivity to sunlight
                                                               Skin Ulcers/Wounds
                                                               Tattoos
                                                               Varicose veins
   Endocrine                                                  Musculoskeletal
                                                               Bursitis
 Change in hat or glove size                                  Joint pain/swelling
 Excessive thirst/urination                                   Prior fracture/sprain
 Glandular or hormone                                         Tendonitis
problem                                                        Weakness of limbs
 Heat or cold intolerance

___________ I am not experiencing any of the above.
INITIAL
Allergies: * PLEASE MARK ANY ALLERIGES YOU MAY HAVE, PLEASE LIST ANY NOT SHOWN

 Yes  No     ANTIBIOTICS                            Yes  No    IODINE                       Yes  No     SEASONAL
 Yes  No     ASPIRIN                                Yes  No    LATEX                        Yes  No     SEDATIVES
 Yes  No     CODEINE                                Yes  No    LODICAINE                    Yes  No     SILVER
 Yes  No     CORTISONE                              Yes  No    LOCAL ANESTHESIA             Yes  No     SULFA DRUGS
 Yes  No     DEMEROL                                Yes  No    NOVACAINE                    Yes  No     TAPE/BAND-AIDS
 Yes  No     FOOD                                   Yes  No    PAIN MEDICATION              Yes  No     TETANUS
 Yes  No     ENVIRONMENTAL                          Yes  No    PENICILLIN                   Yes  No     Other: ___________________
 Yes  No     GENERAL ANESTHESIA                     Yes  No    RADIOGRAPHIC DYE             Yes  No     Other: ___________________

____________ I HAVE NO KNOWN ALLERGIES AT THIS TIME.
INITIAL

Are you a diabetic?  Yes  No

What is the name and phone number of the doctor who treats your diabetes? __________________________________________________

When was the date of your last visit? _________________________

What is your average blood sugar reading? _________________

Are you on blood thinners?          Yes  No

Do you have blood disorders?  Yes  No

Are you now or previously received Chemotherapy or Radiation Therapy?  Yes  No

Are you currently pregnant?  Yes  No How many months? _____________

Are you nursing?  Yes  No



__________ To the best of my knowledge, I have answered the questions on these forms accurately. I understand that
providing incorrect information can be dangerous to my health. I understand that it is my responsibility to inform the
doctor and office staff of any changes in my medical status or insurance changes.

__________ I hereby give Dr. Kales permission to examine and treat my feet medically, surgically, or orthopedically and
to photograph or televise any work he does providing it be used for educational purposes and/or to document my
care. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been
made to me as a result of treatment or examination in the office. Any diagnostic procedures, including x-rays and
photographs are the property of the office. Any fees charges are for interpretive purposed only and not the cost of the
x-ray itself. I understand that these images will be stored in a secure manner that will protect my privacy and that
they will be kept for the time period required by law.

__________ I request that the payment of Authorized Medicare/Insurance Benefits be made either to me or on my behalf
for any services furnished by Bayonet Point Foot Health Center. I authorize any holder of medical information about
me to release to CMS/Insurance Carriers and its agents any information needed to determine these benefits or benefit
related to services. I understand and agree that I am responsible for all charges incurred whether or not paid by
above insurance for the balance of any professional services rendered. I understand that I am responsible for any
charges incurred should my account be sent to a collection agency and for any returned checks. I agree to take full
responsibility for any unpaid balances and that such payment will be made to this physician’s office for services. I
authorize and direct payments to Dr. Kales for the medical and/or surgical benefits payable under the terms of my
insurance. I understand the above and agree to comply.

_____ I have received a copy of Bayonet Point Foot Health Center’s HIPAA Privacy Notice.



Patient Signature: ________________________________________________________________________ Date: ___________________________________________

								
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