Vineland Podiatrist - Advanced Foot & Ankle - Foot Doctor ...
DOWNLOAD DOCUMENT THEN CLICK -ENABLE EDITING- AT TOP TO ALLOW YOU TO FILL OUT FORM ELECTRONICALLY THEN PRINTAND BRING TO THE OFFICE PRIOR TO APPT.FILL OUT ALL YELLOW SECTIONS COMPLETELY(some will have an arrow leading to drop down box then choose item and some will be a box to write in text or both )It would be helpful if possible to drop off at the office at least one day in advance of your appointment as well NAME : FIRST: Click or tap here to enter text. LAST: Click or tap here to enter text.BIRTHDATE: Click or tap here to enter text.Click on ONE: (FEMALE?) (MALE?)SOCIAL SECURITY NUMBER: Click or tap here to enter text. STREET ADDRESS 1: Click or tap here to enter text.STREET ADDRESS 2: Click or tap here to enter text.CITY: Click or tap here to enter text. STATE: Click or tap here to enter text. ZIP CODE: Click or tap here to enter text. HOME PHONE: Click or tap here to enter text. WORK PHONE: Click or tap here to enter text. CELL PHONE: Click or tap here to enter text.**EMAIL (REQUIRED PLEASE PROVIDE) ** : Click or tap here to enter text.ETHNICITY (CLICK ONE): ?NON-SPECIFIC ?HISPANIC LATINO?NON-HISPANIC LATINOPRIMARY LANGUAGE (CLICK ONE): ?ENGLISH?SPANISH? OTHERRACE (CLICK ONE): ?NON-SPECIFIC ? ASIAN ?BLACK/AFRICAN AMERICAN?WHITEFAMILY DOCTOR: Click or tap here to enter text.ARE YOU DIABETIC: (YES?) (NO?) IF YES--WHO IS YOUR TREATING DIABETIC DOCTOR: Click or tap here to enter text.WHO REFERRED YOU TO OUR OFFICE: Click or tap here to enter text.EMERGENCY CONTACT: Click or tap here to enter text. PHONE : Click or tap here to enter text. MESSAGE CAN BE LEFT WITH: Choose an item. MARITAL STATUS: Choose an item. SPOUSE NAME: Click or tap here to enter text.STUDENT STATUS(click one): ?FULL TIME STUDENT (F) ?NOT A STUDENT (N) ?PART TIME STUDENT (P)EMPLOYMENT STATUS: ? EMPLOYED FULL TIME(1) ?EMPLOYED PART TIME(2) ? NOT EMPLOYED(3)RETIRED EMPLOYEES - PLACE OF EMPLOYMENT : Click or tap here to enter text.PLEASE CLICK IF YOU HAVE ONE OF THE FOLLOWING HEALTH SPENDING CARDS (CLICK NONE IF YOU DO NOT HAVE ONE) : ( ? H.S.A. ) ( ? H.R.A. ) ( ? FLEX CARD ) ( ? NONE ) PRIMARY INSURANCE: Choose an item. Click or tap here to enter text.I AM THE (CLICK ONE): (? SELF) (? SPOUSE) (? CHILD) (? OTHER) TO THE ABOVE INSURANCE POLICY POLICY HOLDER NAME: Click or tap here to enter text. POLICY HOLDER DATE OF BIRTH Click or tap here to enter text. SOCIAL SECURITY (REQUIRED FOR BILLING): Click or tap here to enter text. POLICY HOLDER OCCUPATION: Click or tap here to enter text. EMPLOYER: Click or tap here to enter text.SECONDARY INSURANCE: Choose an item. Click or tap here to enter text.I AM THE (CLICK ONE) (? SELF) (? SPOUSE) (? CHILD) (? OTHER) TO THE ABOVE INSURANCE POLICY POLICY HOLDER NAME: Click or tap here to enter text. POLICY HOLDER DATE OF BIRTH Click or tap here to enter text. SOCIAL SECURITY (REQUIRED FOR BILLING): Click or tap here to enter text. POLICY HOLDER OCCUPATION: Click or tap here to enter text. EMPLOYER: Click or tap here to enter text. “I request payment of authorized Medicare benefits (and all insurances) to be made on my behalf to this office for services furnished to me. I authorize any holder of medical information about this patient to be released to Health Care Financing Administration or any insurance company or agents to help determine benefits payable for services rendered. I understand and agree that I will be responsible for the payment of services rendered to the above patient.”“I also understand with today’s managed care systems of insurance, should my insurance require a referral, I realize that I must bring it in before my treatment and that it is my responsibility to request additional referrals from my Primary Care Physician after I have used up the original referrals or they become expired.” “Additionally, should this office find a need to refer me for tests, or any treatment to another facility, I need to call my insurances company and inquire if they participate and if I need referrals or precert. I acknowledge that I was provided with a copy of the Notice of Privacy Practices and I have read (or had the opportunity to read if I so chose)and understood the Notice.” “I also understand that if I do not follow the rules of my insurance company, then I will be responsible for my charges. I have provided the office my email address and give permission the office to contact me via email.”“I authorize this office to request medical records from any of my physicians as well as to release any of my medical records to my physicians.”**ELECTRONIC SIGNATURE(FULL NAME) : Click or tap here to enter text. TODAYS DATE: Click or tap to enter a date.FILL THIS SIDE OUT ONLY IF THE PATIENT ISCOVERED UNDER A PARENT(CLICK ONE):?YES (PLEASE FILL OUT) ?NO (DOES NOT APPLY) FATHER’S NAME: Click or tap here to enter text. FATHER’S DATE OF BIRTH Click or tap here to enter text. FATHER’S SOCIAL SECURITY (REQUIRED FOR BILLING): Click or tap here to enter text. FATHER’S OCCUPATION: Click or tap here to enter text. EMPLOYER: Click or tap here to enter text. FATHER’S WORK PHONE: Click or tap here to enter text. ***MUST CLICK ON ONE BELOW WITH REGARDS TO FATHER****(? FULL-TIME) (? PART-TIME) (? NOT EMPLOYED)(? FULL-TIME STUDENT) (? PART-TIME STUDENT)(? SELF-EMPLOYED) (? MILITARY SERVICE) (? RETIRED) MOTHER’S NAME: Click or tap here to enter text. MOTHER’S DATE OF BIRTH Click or tap here to enter text. MOTHER’S SOCIAL SECURITY (REQUIRED FOR BILLING): Click or tap here to enter text. MOTHER’S OCCUPATION: Click or tap here to enter text. EMPLOYER: Click or tap here to enter text. MOTHERS WORK PHONE: Click or tap here to enter text. ***MUST CLICK ON ONE BELOW WITH REGARDS TO MOTHER****(? FULL-TIME) (? PART-TIME) (? NOT EMPLOYED)(? FULL-TIME STUDENT) (? PART-TIME STUDENT)(? SELF-EMPLOYED) (? MILITARY SERVICE) (? RETIRED)MEDICATIONS (list)medicine dosageCLICK ON BOX TO TYPE MED AND DOSE DO NOT CLICK ENTER TO FOLLOW JUST CLICK ON THE NEXT BOXClick or tap here to enter text. Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text. ? IF NOT TAKING ANY MEDICATIONS, CHECK THIS BOXALLERGIES(list reaction)? aspirin __________________? cephalosporin_____________? codeine_________________? cortisone________________? erythromycin ____________? ibuprofen________________? iodine___________________? latex____________________? novacaine________________? penicillin________________? sulfa drugs_______________? tape____________________? tetracycline______________? Tylenol__________________OTHER:? Click or tap here to enter text.? IF NO ALLERGIES, CHECK THIS BOX -27368434925**ELECTRONIC SIGNATURE(FULL NAME) : Click or tap here to enter text. TODAYS DATE: Click or tap to enter a date. **PHARMACY NAME/LOCATION**: Choose an item.00**ELECTRONIC SIGNATURE(FULL NAME) : Click or tap here to enter text. TODAYS DATE: Click or tap to enter a date. **PHARMACY NAME/LOCATION**: Choose an item. MEDICAL HISTORY? AIDS/HIV? anemia? aortic aneurysm? arthritis-osteoarthritis? arthritis- rheumatoid? asthma? bleeding tendencies? bronchitis? cancer type: Click or tap here to enter text.? congestive heart failure? Crohn’s disease? diabetes? depression? gastric reflux? gout? heart attack? heart valve problems? hepatitis? high blood pressure? irregular heart beat? kidney problems? liver disease? low blood pressure? lupus? mitral valve prolapse? multiple sclerosis? pacemaker? phlebitis? poor circulation? rheumatic fever? seizures? stomach ulcers? thyroid disorder OTHER:? Click or tap here to enter text.? IF NONE, CHECK THIS BOX SURGICAL HISTORY? ankle/foot fracture ? back surgery? bowel surgery? brain surgery? carpal tunnel surgery? colon surgery? eye surgery? foot surgery? heart-artery bypass? hip replacement ? hysterectomy? knee replacement? organ transplant? thyroidectomy? tubal ligation? vascular surgeryOther: ? Click or tap here to enter text.? IF NONE, CHECK THIS BOX SOCIAL HISTORY? alcohol use (social drinker)? alcohol use (heavy drinker)? alcohol (recovering alcoholic)? alcohol use (non-drinker)SOCIAL HISTORY? smoking (former smoker)? smoking (heavy smoker)? smoking (light smoker)? smoking (never smoked)FAMILY HISTORY (CLICK mom or dad)? cancer ? mom ? dad? depression ? mom ? dad? diabetes ? mom ? dad? gout ? mom ? dad? heart disease ? mom ? dad? hypertension ? mom ? dad? osteoarthritis ? mom ? dad? rheumatoid arthritis ? mom ? dad? sickle cell anemia ? mom ?dad? stroke ? mom ? dad? OtherClick or tap here to enter text.? IF NONE, CHECK THIS BOX REVIEW OF SYSTEMS: CLICK all boxes that applyIf “NONE” check “ NONE BOX”CONSTITUTIONAL? anxiety? chills? depression? fever? memory loss? night sweats? panic attacks? weight loss (unintentional)? IF NONE, CHECK THIS BOXCARDIOVASCULAR (CV)? chest pain? color change in feet/legs? leg cramping? leg swelling? pain in calves when walking? varicose veins? pain in feet at night? IF NONE, CHECK THIS BOXENDOCRINE? delayed wound healing? excessive thirst? fatigue? IF NONE, CHECK THIS BOXGENITOURINARY ? difficulty with urination ? burning urination ? frequent urination? IF NONE, CHECK THIS BOXGATROINTESTINAL (GI)268795545720**ELECTRONIC SIGNATURE(FULL NAME) : Click or tap here to enter text. TODAYS DATE: Click or tap to enter a date.00**ELECTRONIC SIGNATURE(FULL NAME) : Click or tap here to enter text. TODAYS DATE: Click or tap to enter a date. ? abdominal pain? blood in stool? constipation? diarrhea? nausea? vomiting? yellowing of skin? IF NONE, CHECK THIS BOXINTEGUMENTARY? burning sensation of skin? excessive scars (keloids)? itchy skin? non-healing wound? IF NONE, CHECK THIS BOXMUSCULOSKELETAL (MSK) ? ankle pain? foot pain? hip pain? joint swelling? leg weakness? low back pain? radiating pain down leg? IF NONE, CHECK THIS BOXNEUROLOGICAL? burning of feet? electric shooting pain in foot? increased sensitivity to touch? numbness of feet or toes? tingling or pricking sensation? IF NONE, CHECK THIS BOXRESPIRATORY? chest tightness? shortness of breath? wheezing? IF NONE, CHECK THIS BOXHistory of present illness (HPI): MAIN PROBLEM/CONCERN *** This is your story---please fill out completely WITH REGARDS TO YOUR MAIN PROBLEM so we can best serve you ***INSTRUCTIONS: Please click on choose an item then click arrow -choose from drop down box or click or tap to enter text**DO YOU HAVE A SECONDARY CONCERN ? NO ? YES - IF YES please fill out a secondary HPI on the next page**Chief Concern: What is your ONE MAIN concern for coming to the office? : Choose an item. Click or tap here to enter text.Nature: Please describe your condition(USE MORE THAN ONE IF NEEDED TO DESCRIBE) : Choose an item. Choose an item. Choose an item. Click or tap here to enter text.Injury: Was there an injury? (please click) : (NO) ? (YES) ? IF YES WHERE DID IT OCCUR ? Choose an item. Click or tap here to enter text.IF YES DESCRIBE THE INJURY : Choose an item. Click or tap here to enter text.Intensity: Please INDICATE the intensity of the pain/discomfort (0 to 10) : ( 0 is no pain, 1 is mild discomfort , 5 is moderate pain, 10 is worst most severe pain ) (CHOOSE ONE): Choose an item.Location: Please be specific as to location of your problem : (PLEASE CLICK ON THE SIDE-- RIGHT OR LEFT OR BOTH): (right foot?) (left foot?) (both feet?) (right ? left ? both? big toe? 2nd toe? 3rd toe? 4th toe? 5th toe?) (right ankle?) (left ankle?) (both ankles?) Click or tap here to enter text.Specific location(BE VERY SPECIFIC): Choose an item. Click or tap here to enter text.Duration: This has been going on for how long? : Choose an item. Click or tap here to enter text.Onset: How did the condition come on? : Choose an item. Click or tap here to enter text.Course: What is the course of the condition/problem? : Choose an item. Click or tap here to enter text.Aggravating Factors: Condition is aggravated by? (choose more than one if needed) : Choose an item. Choose an item. Choose an item. Click or tap here to enter text.Treatment: What treatment have you tried for this condition? (choose more than one if needed) : Choose an item. Choose an item. Choose an item.Click or tap here to enter text. PATIENT NAME: Click or tap here to enter text. DOB: Click or tap to enter a date. TODAY’S DATE: Click or tap to enter a date. ***(IF YOU HAVE A SECONDARY CONCERN please fill out THIS secondary HPI ***Chief Concern: What is your SECONDARY concern for coming to the office? : Choose an item. Click or tap here to enter text.Nature: Please describe your condition(USE MORE THAN ONE IF NEEDED TO DESCRIBE) : Choose an item. Choose an item. Choose an item. Click or tap here to enter text.Injury: Was there an injury? (please click) : (NO) ? (YES) ? IF YES WHERE DID IT OCCUR ? Choose an item. Click or tap here to enter text.IF YES DESCRIBE THE INJURY : Choose an item. Click or tap here to enter text.Intensity: Please INDICATE the intensity of the pain/discomfort (0 to 10) : ( 0 is no pain, 1 is mild discomfort , 5 is moderate pain, 10 is worst most severe pain ) (CHOOSE ONE): Choose an item.Location: Please be specific as to location of your problem : (PLEASE CLICK ON THE SIDE-- RIGHT OR LEFT OR BOTH): (right foot?) (left foot?) (both feet?) (right ? left ? both? big toe? 2nd toe? 3rd toe? 4th toe? 5th toe?) (right ankle?) (left ankle?) (both ankles?) Click or tap here to enter text.Specific location(BE VERY SPECIFIC): Choose an item. Click or tap here to enter text.Duration: This has been going on for how long? : Choose an item. Click or tap here to enter text.Onset: How did the condition come on? : Choose an item. Click or tap here to enter text.Course: What is the course of the condition/problem? : Choose an item. Click or tap here to enter text.Aggravating Factors: Condition is aggravated by? (choose more than one if needed) : Choose an item. Choose an item. Choose an item. Click or tap here to enter text.Treatment: What treatment have you tried for this condition? (choose more than one if needed) : Choose an item. Choose an item. Choose an item.Click or tap here to enter text. PATIENT NAME: Click or tap here to enter text. DOB: Click or tap to enter a date. TODAY’S DATE: Click or tap to enter a date. ................
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