Name First Middle Last Date MM slash DD slash YYYY Age Male Female Height Weight Shoe Size Do you have children? Yes No ages Address Street Address PO Mailing Address(if applicable) City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneWork PhoneOccupation Retired? Yes No Email Address(please Print clearly) Marital Status: Single Committed relationship Married Widowed Separated Divorced Spouse/Partner Name Date of Birth MM slash DD slash YYYY Is patient a minor? Name of parent or guardian Address of parent or guardian, if different Street Address City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneWork Phone Best Contact InformationHome PhoneCell PhoneWork PhoneEmergency Contact Cell PhoneRelationship Payment And Insurance Information Check here if no health insurance Full Name of Insured Relationship to Patient Insured Date of Birth Insured Employer Employer Address According to my insurance, I am required to pay a co-payment amount $ Deductible amount$ We require co-payment at time of service. We accept-cash, checks, Visa, Mastercard, and Discover. My insurance requires a referral from my primary care physician before I see a specialist: Yes No Referral Information We appreciate referrals! Whom may we thank for referring you to our office? Name Address Is this person your: Primary Care Physician Other Specialist Family Member Friend Is this person your: Internet Search Our Website Phone Book Saw Our Sign Newspaper ad, which paper? Insurance plan or website? Other (tell us more)! PODIATRIC HISTORYHave you ever been to a podiatrist before? Yes No What is the chief foot complaint for which you came to be treated?When did it begin? Did you receive treatment for this condition? Yes No If so, what type?Circle the degree of pain you are currently experiencing: 1 2 3 4 5 6 7 8 9 10 Have you ever had any of the following foot conditions? Ankle instability In toe/out toe walking Arthritis Back pain Blisters Bonespurs Bunions Burning feet Corns/calluses Diabetic evaluation Fungal infections Gout Hammertoes Heel pain DHip pain Infections Ingrown toenails Joint pain Kneepain Limb length discrepancy Neuromas Numbness or tingling Plantar fasciitis Postural fatigue Pronation Shin splints Sprains Sweating/odor Tendonitis Tired feet Ulcers Warts Have you ever been treated for any of the following conditions? Please v all that apply to you, put an M if on your mother's side and a P if on your father's. Acid reflux Hypothyroidism Anemia Irritable Bowel Syndrome Arthritis Kidney problems Asthma Liver disease Bleeding disorders Low blood pressure Cancer Muscle or joint pain Depression Nervous disorder Diabetes Peripheral artery disease Epilepsy Parkinson's disease Fatigue Phlebitis Fibromyalgia Poor circulation Headaches Respiratory disease Heart condition Rheumatic fever Hepatitis Shortness of breath High cholesterol Seizure disorder HIV/AIDS Stomach ulcer Hypertension Stroke Hyperthyroidism Varicose veins MEDICATIONAre you currently on blood thinners? Yes No You can provide a printout of your medications or list them below:Medicine nameStrength/mgHow often? Do you currently use cigarettes or tobacco? Yes No If yes, how long? If yes, how long? If quit, how long? Yrs If quit, how long? Alcohol use? Yes No If yes, quantity Daily Monthly SURGERIESPlease list all surgeries / Approximate dateName of MD/family physician Name of MD/family physician Address Street Address Date of last visit MM slash DD slash YYYY ALLERGIES Have you ever had any adverse effects or an allergy to:Adhesive tape Yes No Anticoagulants Yes No Aspirin Yes No Codeine Yes No Cortisone Yes No Iodine Yes No Latex Yes No Metal/jewelry Yes No Novocaine Yes No NSAIDs Yes No Peanuts Yes No Penicillin Yes No Seafood Yes No Seafood Yes No Antibiotics Yes No Pain medication Yes No Other Yes No If other, please explain: SIGNATURE OF FILE AND PERMISSION TO TREAT • I understand that the information provided on this form is true and correct to the best of my knowledge. • I request that payments of authorized benefits be made on my behalf for any services furnished by Acton Foot and Ankle. • I authorize any holder of information about me to release any information needed to determine these benefits or the benefits payable to related services to the insurance agent. • I recognize my financial obligation of an co-insurance, co-payments, or deductibles and non-covered services that may be required. • I hereby give permission to Acton Foot and Ankle and any qualified staff to evaluate, diagnose and treat my foot and/or ankle condition as may be deemed necessary Patient or authorized signature:If not patient, state relationship: Date MM slash DD slash YYYY