PATIENT INFORMATION SHEET:

MR# Last Name: Street City Phone: ( Sex: M Employer: Work phone: ( ) DL State F ) Birthdate: Cell: ( ) Single State Zip Social Security #: Married Widowed Other First Name/MI:

Marital Status:

Occupation Number

Spouse Name: Employer:

Birthdate Business phone: ( ) -

Responsible Party (If Other Than Patient or Spouse): Wife Last Name: Street: Phone: ( ) -

Husband

Parent

Other

First Name/MI: City/State: Birthdate: Zip:

Who May We Thank For Referring You To Our Office? Television commercial Your Primary Care Physician: Who May We Contact In Case Of An Emergency? Phone #: ( ) Internet Yellow Pages Phone: ( ) -

I authorize the release of any medical information necessary to process any claim. I authorize payment of benefits either to myself or to Triad Foot Center, PA as agreed upon at the time of treatment for services rendered. I understand I am liable for any deductibles, copays or non-covered services. I also verify I have provided The Triad Foot Center with my correct insurance information. If it is incorrect, I will be responsible for the full monetary amount of all my services. This authorization shall be valid unless rescinded by one at a later date.

Signature:

Date:

ALL COPAYMENTS ARE DUE AT THE TIME OF SERVICE

PATIENT HEALTH HISTORY

DOB

WHY ARE YOU HERE TODAY?

ANSWER YES or NO: Are you pregnant? Do you have diabetes? LIST PAST SURGERIES

Do you have HIV?

Family member with diabetes?

REVIEW OF SYSTEMS AND MEDICAL CONDITIONS:

HEENT None Glaucoma Sore Throat/ Difficulty Swallowing Dizziness Nose Bleeds Hearing Loss or Ringing Sinus Problems Other____________ MUSCULOSKELETAL None Gout Muscle Pain or Cramps Osteoarthritis Rheumatoid Arthritis Osteoporosis Swelling of the feet or legs Other_________________ ENDOCRINE None Thyroid Disease Diabetes Other_________________ CONSTITUTIONAL None Recent Weight Change Fatigue Night Sweats Fever Other_______________

CARDIOVASCULAR None Angina Calf Pain When Walking Poor Circulation Blood Clots Legs/Lung Peripheral Artery Disease High or Low Blood Pressure History of Heart Attack/Stroke Dates: _____________________ Chest Pain Palpitations Other____________ GENITOURINARY None Kidney Disease Bladder Problems Other_________________

RESPIRATORY None Asthma Cough Difficulty Breathing Emphysema Other____________ GASTROINTESTINAL None Irritable Bowel Syndrome Stomach Ulcer Reflux Liver Disease HEMATOLOGIC None Anemia Bruise Easily Blood Clotting Disorder Slow To Heal Other____________ NEUROLOGICAL / PSYCHIATRIC None Frequent Headaches/Migraines Seizures or Convulsions Depression Paralysis or Tremors Anxiety Memory Loss
continued on back

SKIN None Change in Hair or Nails Thick Scars Open Sores Rashes Skin Cancer Other_______________

SOCIAL HISTORY & DAILY LIVING

TOBACCO USE

Yes

No

Past

_______ PACK PER DAY ______ YEARS

STOPPED / LAST USE: ________________ ALCOHOL USE Yes No Social LESS THAN 2 DRINKS PER DAY MORE THAN 2 DRINKS PER DAY No Past

STOPPED / LAST USE: ________________ RECREATIONAL DRUG USE Yes

STOPPED / LAST USE: ________________

FAMILY INFORMATION MOTHER: living; current age __________ or cause of death: FATHER: living; current age __________ or cause of death: Please check if there is a history with either parent (indicate which one) for any of the following: CANCER BLEEDING PROBLEMS STROKE RHEUMATOID ARTHRITIS PROBLEMS WITH ANESTHESIA BLOOD CLOTS DIABETES HIGH BLOOD PRESSURE GOUT deceased; age at time of death __________ deceased; age at time of death __________

I have read and understand the patient information forms. The information that I have provided in these forms is correct to the best of my knowledge.

Patient Signature

Date

If the patient is a minor (under 18 years of age) or is otherwise unable to sign on their own behalf, the patient representative who completed these forms should complete the following information:

Patient Signature Name Relationship to Patient:

Signature

Authorization for Release of Information

is authorized to release protected health information about the above named patient to the entities named below. The purpose is to inform the patient or others in keeping with the patients instructions. Entity to Receive Information. Check each person/entity that you approve to receive information. Description of information to be released. Check each that can be given to person/entity on the left in the same section.

q Voice Mail

q Results of lab tests/x-rays q Other q Financial q Medical as follows: q Financial q Medical as follows: q Financial q Medical as follows:

q Spouse

q Parent (provide name)

q Other (provide name)

Patient Information I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed as described in this document, I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective going forward. I understand that information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. This authorization shall be in effect until revoked by the patient. Date Signature of Patient or Personal Representative Description of Personal Representatives Authority (attach necessary documentation) Revised 1/08

PATIENT MEDICATION LIST

Date

MR#

PATIENT NAME

DOB

Pharmacy Name

Phone #

Medication

Medication

ALLERGIES:
_____ PeNicilliN _____ latex

_____ NONE (No Known Allergies)

_____ SEASONAL ALLERGIES

_____ asPiRiN _____ DaRvocet

_____ coDeiNe _____ fooD

_____ aDhesive taPe

_____ eNviRoNMeNtal

_____ otheR

tyPe of ReactioNs

Acknowledgement of Receipt Of Notice of Privacy Practices

I have received a copy of the Notice of Privacy Practices for the above named practice. Signature Date

For Office Use Only

We were unable to obtain a written acknowledgement of receipt of the Notice of Privacy Practices because:
q An emergency existed & a signature was not possible at the time. q The individual refused to sign. q A copy was mailed with a request for a signature by return mail. q Unable to communicate with the patient for the following reason:

q Other:

Prepared By Signature Date