Chart#____________
Date______________
Please print:
Name____________________________________________Age__________Birthdate_______________
Address______________________________________________________________________________
City__________________________________________________State__________Zip______________
Sex_____ M_____F ______Single______Married______Widowed______Separated______Divorced
Home phone____________________ Worked phone___________________ SS#________________
Employer_____________________________________________________________________________
Business Address_______________________________________________________________________
Occupation___________________________________________________________________________
Spouse’s Name________________________________________________________________________
Employer_____________________________________________________________________________
Address______________________________________________________________________________
INSURANCE
Primary________________________________________________ Group#_______________________
ID#________________________________ Insured’s Name___________________________________
Birthdate_______________ Employer______________________________ Relationship____________
Secondary Insurance______________________________________Group#_______________________
ID#________________________________ Insured’s Name___________________________________
Birthdate_______________ Employer______________________________ Relationship____________
Medical doctor/Address_________________________________________ Phone#________________
Referred by__________________________________________________________________________
In case of Emergency notify_________________________________Phone#______________________
I, the undersigned give my permission to Columbia Foot Clinic to examine my feet. I also, give
Columbia Foot Clinic permission to file my insurance for services rendered when applicable. I
authorize the use of this signature on all insurance submissions. I am aware that I am
ultimately responsible for the payment of services rendered to me at time of visit.
Responsible party signature Relationship Date
What type of problem are you having with your foot/feet? __________________________________
__________________________________________________________________________________________
How long have you had this problem? _____________________________________________________
What previous treatment have you had, if any? _____________________________________________
Is your problem due to injury? _____________________________________________________________
Have you had previous care by a Podiatrist? ______yes ______ no When?
________________________
Are you presently under a Doctor’s care? _______ yes ______ no
If yes for what reason(s)? _________________________________________________________________
For women of child bearing age: Any chance you may be pregnant? ______yes _____no
Please Circle if you have ever had any of the following conditions:
Diabetes Circulation Problems Arthritis Kidney Disease
Low Blood Sugar High Blood Pressure Infections Liver Disease
Heart Condition Low blood Pressure Phlebitis Asthma
Chest Pain Bowel/Stomach ulcers Hay fever HIV Positive
Gout Cancer Lung Disease AIDS
Hepatitis Thyroid Disorders Other: _____________________________
Have you been exposed to Hepatitis B and/or AIDS? _________________________________________
Please list any medications you are allergic to: ______________________________________________
____________________________________________________________________________________________
List any surgeries performed and hospitalizations: __________________________________________
____________________________________________________________________________________________
List any medications you are presently taking: ______________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Do you smoke? _______yes _______ no If so, how much? ____________________________________
Do you drink? ________yes _______ no If so, how much? ___________________________________
Do you use recreational drugs? _____yes _____no What kind? _______________________________
Signature _______________________________________________________ Date ____________________