CHART NO: YAMHILL COUNTY FOOT HEALTH CENTER DATE:
PATIENT INFORMATION
Name: ___________________________________________________ Social Security #: _________________
(Last) (First) (Middle)
Mailing Address: _____________________________________________________________________________
(Street) (City) (Zip)
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 Yes __ No __ Ulcers Yes __ No __
Cancer/Malignancy Yes __ No __ Hepatitis Yes __ No __
Diabetes Type I or II Yes __ No __ Liver Problems Yes __ No __
Skin Changes Yes __ No __ Kidney Problems Yes __ No __
HIV or AIDS Yes __ No __ Bowel Problems Yes __ No __
Dizziness/Fainting Yes __ No __ Gout Yes __ No __
Seizures Yes __ No __ Psoriasis Yes __ No __
Visual Problems Yes __ No __ Pulmonary emboli Yes __ No __
Hearing Difficulties Yes __ No __ Tuberculosis Yes __ No __
Asthma Yes __ No __ Pneumonia Yes __ No __
Thyroid Problems Yes __ No __ Bleeding Problems Yes __ No __
Stroke Yes __ No __ Blood clots in leg Yes __ No __
Heart Attack Yes __ No __ Pain in calves w/walking Yes __ No __
Shortness of Breath Yes __ No __ Problems with general anesthesia
Chest pain/Angina Yes __ No __ YOU Yes __ No __
High Blood Pressure Yes __ No __ FAMILY Yes __ No __
Rheumatic Fever Yes __ No __ Problems with local
Rheumatoid Arthritis Yes __ No __ anesthesia Yes __ No __
Arthritis (other) Yes __ No __ Previous Injuries Yes __ No __
Varicose veins Yes __ No __
Indicate any sensitivity to the following: Do you use:
Novocain ___ Soaps___ Latex ___ Tobacco: ____ How much: ____ pack/day ____ # of years
Iodine ___ Tape ___ Other ___ 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 __