Chart#____________ Date______________ Please print: Name____________________________________________Age__________Birthdate_______________ Address______________________________________________________________________________ City__________________________________________________State__________Zip______________ Sex_____ M_____F ______Single______Married______Widowed______Separated______Divorced SS#________________
Home phone____________________ Worked phone___________________
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 Low Blood Sugar Heart Condition Chest Pain Gout Hepatitis Circulation Problems High Blood Pressure Low blood Pressure Bowel/Stomach ulcers Cancer Thyroid Disorders Arthritis Infections Phlebitis Hay fever Lung Disease Kidney Disease Liver Disease Asthma HIV Positive AIDS
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 ____________________