CHART NO:
YAMHILL COUNTY FOOT HEALTH CENTER
PATIENT INFORMATION
DATE:
Name: ___________________________________________________
(Last) (Street) (First) (Middle) (City)
Social Security #: _________________
(Zip)
Mailing Address: _____________________________________________________________________________ Age: ________ Date of Birth: _________________________ Sex: M F Marital Status: S M D W
Home Phone: _________________________
Mobile: ___________________ Work: _____________________
Employer: ___________________________________________ Occupation: _____________________________ Spouse or Parent’s Name: _______________________________________________________________________ Spouse or Parent’s Employer: ___________________________ Work Phone: _____________________________ Primary Care Physician: ________________________________________________________________________ By whom were you referred (how did you hear about us)? _____________________________________________ Primary Medical Insurance: Name of Insurance Company: ___________________________________________________________________ Address: ____________________________________________________________________________________ Name of Subscriber: ___________________________________ Employer: ______________________________ ID Number: __________________________________________Group Number: __________________________ Secondary Medical Insurance: Name of Insurance Company: ___________________________________________________________________ Address: ____________________________________________________________________________________ Name of Subscriber: ___________________________________ Employer: ______________________________ ID Number: __________________________________________Group Number: __________________________ Credit Policy:
We will be happy to bill your primary insurance company for you provided we have all the necessary information, or we can provide a complete form for you to send to your insurance company. If your address or insurance coverage changes, please notify us as soon as possible. Statements are sent monthly. The end of the billing period is the 20th of each month. Any payments or credits after the 20th will be reflected on the next statement. We allow 60 days for insurance processing. If your insurance company has not responded within that time, payment is expected from you. A regular monthly payment plan can be arranged if you are unable to pay the entire balance in full. Final responsibility for payment of your account is yours. Accounts over 60 days old will be subject to an overdue account charge of $5.00/month or 1% of the balance owing, whichever is greater. If we do not receive payment from you at that time, you will be given a final notice and your account may then be turned over to an outside collections agency. You will be charged for any collection and/or attorney’s fees. Your signature certifies that you have read, understand, and agree to the credit policy stated above, authorize the release of any medical information necessary to process this claim for services rendered, and authorize payment of medical benefits to Yamhill County Foot Health Center for services described on itemized statements and/or insurance forms.
Signature (Patient/Parent/Guardian): _____________________________________________________ Date: ____________ Name (Please Print): ___________________________________________________________________________________
CHART NO:
YAMHILL COUNTY FOOT HEALTH CENTER
DATE:
Why are we seeing you today?
Patient’s Name: ________________________________________
Primary problem: _____________________________________________________________________________________ Where is the problem located: ________________________________ Date problem started: _________________________ When does it hurt: _____________________________________________________________________________________ Is the pain (circle all that apply): Sharp/Dull/Throbbing/Burning/Shooting/Continuous/Intermittent/Localized/Other Does anything make the pain better or worse: _______________________________________________________________ Have you had any prior treatments for this problem (please describe): ____________________________________________ ____________________________________________________________________________________________________ Please indicate if you have a history of any of the following (use back of page for additional information):
Presently Pregnant or Nursing Cancer/Malignancy Diabetes Type I or II Skin Changes HIV or AIDS Dizziness/Fainting Seizures Visual Problems Hearing Difficulties Asthma Thyroid Problems Stroke Heart Attack Shortness of Breath Chest pain/Angina High Blood Pressure Rheumatic Fever Rheumatoid Arthritis Arthritis (other) Varicose veins Novocain ___ Iodine ___ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ No __ No __ No __ No __ No __ No __ No __ No __ No __ No __ No __ No __ No __ No __ No __ No __ No __ No __ No __ No __ Ulcers Hepatitis Liver Problems Kidney Problems Bowel Problems Gout Psoriasis Pulmonary emboli Tuberculosis Pneumonia Bleeding Problems Blood clots in leg Pain in calves w/walking Problems with general anesthesia YOU FAMILY Problems with local anesthesia Previous Injuries Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ Yes __ No __ No __ No __ No __ No __ No __ No __ No __ No __ No __ No __ No __ No __ No __ No __ No __ No __
Indicate any sensitivity to the following:
Soaps___ Latex ___ Tape ___ Other ___
Do you use:
Tobacco: ____ How much: ____ pack/day ____ # of years Alcohol: ____ How much: ____ drinks/day/week
Allergies (include type of reaction): ______________________________________________________________________ Hospitalizations/Surgeries (include year):_________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Illnesses: ___________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Current Medications (including all non-prescription medications and dosages): ___________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Family History:_______________________________________________________________________________________
Please check here if more information has been added to the back of the page __