Patient Podiatric and Health Information

Family Physician _____________________________________________________________________________________________________

Last Visit ___________________________________________________________________________________________________________

What is the nature of your foot problem? _________________________________________________________________________________

Height ______________________________________ Weight ____________________________ Shoe Size ____________________________

Are you in good general health?  ____  Y    ____ N    If no, explain _____________________________________________________________
Are your feet tired at the end of the day?  ____  Y   ____  N           Do you have lower back pain?  ____  Y   ____  N  
Have you ever broken a bone in your foot or ankle?  ____  Y   ____  N           Have you had previous foot/ankle surgery ?  ____  Y   ____  N  
Do you use tobacco products?  ____  Y   ____  N           If yes, what amount daily ______________________________
 
 
Medical History
Check if you have had any of the following:
 ____  Arthritis, Rheumatism      ____  Cramps/Numbness in feet or legs      ____  Heart trouble      ____  Liver trouble
 ____  Asthma      ____  Diabetes      ____  High blood pressure      ____  Swelling of feet or ankles
 ____  Bleeding disorder      ____  Eye trouble      ____  Kidney trouble      ____  Varicose veins
 
 
Are you allergic/sensitive to:
 ____  Anesthetics      ____  Materials      ____  Tape
 ____  Drugs      ____  Novocain     Other ____________________________________________
 ____  Foods      ____  Penicillin     _________________________________________________
Authorization

I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge. I understand that this information will be used by the doctor to help determine appropriate treatment. If there is any change in my medical status, I will inform the doctor.

I authorize my insurance company to pay the doctor or medical group all insurance benefits otherwise payable tome for services rendered. I authorize the use of this signature on all insurance submissions.

I authorize the doctor to release all information necessary to secure the payment of benefits. I understand than I am financially responsible for all charges whether or not paid by insurance.

Signature ________________________________________________________________ Date ______________________________________
Payment is due in full at time of treatment unless prior arrangements have been approved