DANIEL KORMYLO, DPM – NEW PATIENT FORM
DANIEL KORMYLO, DPM
745 Route 25A – Suite B
Rocky Point, NY 11778
631-744-8282 Email drkdpm@
Name: _________________________________________ Date of Birth _________________________
Sex: M F Marital Status: Single Married Widowed Divorced
Address: ______________________________________ City: _____________________State: ______ Zip: ____________
Home Phone: ______________________________________Cell/Alt: ___________________________________________
SS# ______________________________________________E-mail: ______________________________________
Height __________ Weight __________ Shoe Size: ___________ Blood Pressure: ______________/_________________
Pharmacy: _________________________________Location/phone____________________________________________
Primary Care Physician: _____________________________ Phone: ___________________ Date last seen: ___________
Previous Podiatric Physician: _________________________ Phone: ___________________ Date last seen: ___________
PRIMARY INSURANCE: __________________________________________________ Are you the insured: yes no
POLICY ID: ____________________________________________________
INSURED INFORMATION:
SUBSCRIBER NAME: _________________________________ Relationship to insured: spouse child self other
Group ID: ______________________________________ Sex: Male Female DOB: ______________________
SECONDARY INSURANCE:
INSURANCE NAME: ___________________________________ POLICY ID: ________________________________
SUBSCRIBER NAME: _________________________________ Relationship to insured: spouse child self other
Group ID: ______________________________________ Sex: Male Female DOB: ______________________
How did you find out about our practice? Physician Internet Telephone book Family member Friend
Other: ____________________________________________________
What is the reason for your visit today? ________________________________________________________________
__________________________________________________________________________________________________
How long has this bothered you? 1 2 3 4 5 6 7 days weeks months years
What treatments have you tried & have they been effective? ______________________________________________
__________________________________________________________________________________
On a scale of 1 -10 (1 being no pain and 10 being the worst) what is your level of pain? ___________/10
The pain quality is: burning constant dull sharp shooting throbbing tingling other __________
PLEASE READ AND SIGN
The above information is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above.
PATIENTS SIGNATURE: __________________________________________________ DATE: ____________________________________________
NAME_________________________________________DATE OF BIRTH _____________________________
Medical History: ο Alcoholism ο Blood disorders ο Circulation problems ο musculoskeletal ο breathing issues
ο Liver ο Sleep apnea ο Heart Murmur ο High blood pressure ο Heart disease ο Asthma
ο Gout ο Depression ο Anxiety ο Stomach/bowel ο Mental Illness οBlood Clot
ο Kidney ο Diabetes (type 1, type 2) ο Neurological (specify) ________________ ο Skin disorders
ο Arthritis (specify) _____________________ ο Thyroid (specify) ____________________
ο Other (specify) ____________________________________________________________________________________
LAST FLU SHOT DATE: __________________ DID YOU GET A PNEUMOCOCCAL VACCINATION? YES NO
Surgical History Yes No
Have you ever had any surgical procedures on foot/ankle or anywhere else on you body? Yes No
If yes, please describe: _____________________________________________________________________________________
Do you have any artificial joints? Yes (where? ______________) No Do you have an artificial heart valve? Yes No
Social History
Do you smoke? Yes No Former Smoker When did you quit? _____________________________________________
Do you drink alcohol? Yes, everyday (5-7 days/week) Yes, occasionally/socially No/Rarely
What is your occupation? _______________________________________ Does it involve mostly standing or sitting
Advanced directives: Yes No Surrogate decision maker name: _______________________________
Family History Is there any family history (blood relative) of:
ο Mother ο Diabetes type _______ ο Cancer type _________________ ο Heart disease ο Other:_____________________
ο Father ο Diabetes type _______ ο Cancer type ________________ ο Heart disease ο Other:_____________________
ο Sister ο Diabetes type _______ ο Cancer type ________________ οHeart disease ο Other:_____________________
ο Brother ο Diabetes type _______ ο Cancer type ________________ ο Heart disease ο Other:_____________________
ο Grandmother ο Diabetes type ______ ο Cancer type _____________ ο Heart disease ο Other:_____________________
ο Grandfather ο Diabetes type ______ ο Cancer type _____________ ο Heart disease ο Other:_____________________
Current Medications ____ None _____ I take the following Prescription or over the counter medications:
Name: _______________________________ For: _________________________ Dose: __________ How often: ___________
Name: _______________________________ For: _________________________ Dose: __________ How often: ___________
Name: _______________________________ For: _________________________ Dose: __________ How often: ___________
Name: _______________________________ For: _________________________ Dose: __________ How often: ___________
Name: _______________________________ For: _________________________ Dose: __________ How often: ___________
Name: _______________________________ For: _________________________ Dose: __________ How often: ___________
Allergy ο No Known Allergies ο Penicillin ο Shellfish ο Sulfa ο Tape ο Latex ο Iodine ο Aspirin
ο Tylenol ο Ibuprofen ο Codeine ο Other _______________________________________________________
Review of Systems (Please check the box if you currently have any of these symptoms)
Cardiovascular ο Leg pain when walking ο nausea ο fever ο chest pain ο chest pressure/angina ο vomiting
ο leg cramps ο chills ο leg swelling ο cold hands/feet ο weight gain/ weight loss ο leg cramps
ο High blood pressure/hypertension
Genitourinary ο blood in urine ο hesitancy ο incontinence ο decreased frequency
Gastrointestinal ο kidney disease ο diarrhea ο currently pregnant ο kidney stones ο indigestion ο excessive urination
ο blood in stool ο vomiting ο abdominal pain ο heartburn ο Ulcers
Integumentary ο athletes foot ο nail abnormalities ο keloids ο itchiness ο dry, scaly skin
Hematologic ο lower leg ulcers ο bleeding problems ο sickle cell disease ο use blood thinners ο anemia ο rash
ο clotting disorders
Neurological ο tingling ο weakness ο seizures ο numbness
Musculoskeletal ο muscle pain ο back pain ο neck pain ο joint swelling ο sciatica ο tremors ο joint stiffness
ο Paralysis ο joint pain ο muscle weakness ο joint instability
Respiratory ο chest pain ο coughing ο difficulty breathing ο snoring ο asthma ο shortness of breath
ο wheezing other _____________________________________
PLEASE READ AND SIGN
The above information is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above.
PATIENTS SIGNATURE: __________________________________________________ DATE: ____________________________________________
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