New Patient Automated Form



00001600200000-11430080454500160020021590“YOUR FEET NEED A DOCTOR OF THEIR OWN”00“YOUR FEET NEED A DOCTOR OF THEIR OWN”1600200137160Dr. David M. Fischman – Podiatrist901 W. Indiantown Rd, Suite 15Jupiter, FL 33458(561) 575-2266 * Fax: (561) 745-851000Dr. David M. Fischman – Podiatrist901 W. Indiantown Rd, Suite 15Jupiter, FL 33458(561) 575-2266 * Fax: (561) 745-8510Patient Name: FORMTEXT ?????Date of Birth: FORMTEXT ?????Florida Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip: FORMTEXT ?????Out of State Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip: FORMTEXT ?????Primary Phone #: FORMTEXT ?????Secondary Phone#: FORMTEXT ?????Marital Status: FORMDROPDOWN Social Security Number: FORMTEXT ?????Male: FORMCHECKBOX Female: FORMCHECKBOX Guardian for Minor less than 18 years old: FORMTEXT ?????Email Address: FORMTEXT ?????Primary Language Spoken: FORMDROPDOWN Employer name/ phone number: FORMTEXT ?????Spouse’s name/number: FORMTEXT ?????Emergency Contact: FORMTEXT ?????Family Doctor name and phone number: FORMTEXT ?????When was the previous time you visited Family Doctor: FORMTEXT ?????Drug Store name and phone number: FORMTEXT ?????How did you hear about out office? FORMTEXT ?????I give permission to Fischman Foot & Ankle to release any information requested by my insurance company. I also give permission for Fischman Foot & Ankle to perform general procedures in the diagnosis and/or treatment of my foot condition. I authorize payment of medical benefits to Fischman Foot & Ankle for service provided. FORMTEXT ?????Patient/Guardian SignatureDateWhat is the chief complaint for which you came to be treated? (Include foot, ankle and leg) FORMTEXT ?????When did it start? FORMTEXT ?????What treatment have you tried before? FORMTEXT ?????ALLERGIES FORMCHECKBOX Adhesive Tape FORMCHECKBOX Aspirin FORMCHECKBOX Codeine FORMCHECKBOX Demerol FORMCHECKBOX Iodine FORMCHECKBOX Local Anesthetics FORMCHECKBOX Novocaine FORMCHECKBOX No Allergies FORMCHECKBOX PenicillinOther FORMTEXT ?????MEDICAL HISTORY FORMCHECKBOX Aids / HIV FORMCHECKBOX Anemia FORMCHECKBOX Anxiety FORMCHECKBOX Arthritis FORMCHECKBOX Artificial Heart Value/Joints FORMCHECKBOX Bleeding Disorders FORMCHECKBOX Blood Clot/DVT FORMCHECKBOX Cancer/Type FORMCHECKBOX Circulatory Problems FORMCHECKBOX Depression FORMCHECKBOX Diabetic (Enter “1” for TYPE-1, or “2” for TYPE-2) FORMCHECKBOX Epilepsy/Seizures FORMCHECKBOX Flu Shot FORMCHECKBOX Glaucoma FORMCHECKBOX Gout FORMCHECKBOX Heart Disease FORMCHECKBOX Hepatitis FORMCHECKBOX Phlebitis FORMCHECKBOX High Blood Press FORMCHECKBOX Respiratory FORMCHECKBOX High Cholesterol FORMCHECKBOX Shingles Shot FORMCHECKBOX Hypothyroidism FORMCHECKBOX Stomach Ulcers FORMCHECKBOX Kidney Problems FORMCHECKBOX Stroke FORMCHECKBOX Liver Disease FORMCHECKBOX Varicose Veins FORMCHECKBOX Low Blood Press FORMCHECKBOX OtherHave you seen a Podiatrist before?Please indicate any family history of foot or ankle problems:If yes, Name: FORMTEXT ?????Ankle Pain FORMCHECKBOX Athletes Foot FORMCHECKBOX Bunions FORMCHECKBOX Last Visit: FORMTEXT ?????Corns and Calluses FORMCHECKBOX Flat Foot FORMCHECKBOX Foot/Leg Cramps FORMCHECKBOX Previous Foot Problems: FORMTEXT ?????Heel Pain FORMCHECKBOX Ingrown Toenails FORMCHECKBOX Numbness Foot/leg FORMCHECKBOX Plantar Warts FORMCHECKBOX Swelling Ankles/Feet FORMCHECKBOX Tired Feet FORMCHECKBOX Other FORMCHECKBOX MEDICATIONS Please list all medications with dosage and strength FORMTEXT ?????SURGICAL HISTORY Please list any surgeries you have had FORMTEXT ?????SOCIAL HISTORYDo you smoke FORMCHECKBOX Amount FORMTEXT ?????Per day / weekDo you drink alcohol FORMCHECKBOX Amount FORMTEXT ?????Per day / weekSHOE SIZE FORMTEXT ?????WIDTH FORMTEXT ?????HEIGHT FORMTEXT ?????WEIGHT FORMTEXT ????? ................
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