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In-Office
Telemedicine
PRINE Podiatry
Our Doctor
Services
Podiatry
Wound Care
Swift Technology for Verrucae Treatment
OnyFix Nail Correction
Medical Cannabis
Patient Info
Patient Forms
Newsletters
Testimonials
Video Library
Contact Us
Schedule An Appointment
In-Office
Telemedicine
Elementor #17360
Page
1
of 3
Name:
DOB:
SS#:
Sex:
M
F
Marital Status:
Single
Married
Widowed
Divorced
Email address
*
Spouse/Partner Name:
Emergency Name:
Emergency Name:
Address:
City:
State:
Zip:
Home #:
Cell #:
Other #:
Employer:
Phone:
Employer Address:
City:
State:
Zip:
Primary Insurance:
Are you the insured?
Yes
No
Insured Information
Subscriber Name:
Relationship to insured:
Spouse
Child
Self
other
Phone #:
Sex:
Male
Female
DOB:
Address:
Policy ID:
Group ID:
Employer:
Secondary Insurance:
Are you the insured?
Yes
No
Subscriber Name:
Relationship to insured:
Spouse
Child
Self
other
Phone #:
Sex:
Male
Female
DOB:
Address:
Policy ID:
Group ID:
Employer:
How did you find out about our practice?
Physician
Internet
Telephone book
Family member
Friend
Other
What is the reason for your visit today?
Result of accident or work injury?
Yes
No
How long has this bothered you?
1
2
3
4
5
6
7
Days
Weeks
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?
1
2
3
4
5
6
7
8
9
10
The pain quality is:
burning
constant
dull
sharp
shooting
throbbing
tingling
Other
Email address
*
Next
History and Physical
Name:
DOB:
Medical History:
Liver
Heart murmur
Blood clot
Neuropathy
Arthritis
Alcoholism
Sleep apnea
Stomach/bowel
High cholesterol
Blood disorders
Gout
Depression
Thyroid disease
Circulation problems
Anxiety disorder
High blood pressure
Muysculoskeletal
Heart disease
Mental illness
Cancer
Diabetes (type 1, type 2)
HIV
Skin disorders
Breathing issues
Asthma
Kidney disease
Hepatitis
CVA
Stroke
other
(specify)
Are you pregnant?
Yes
No
Are you nursing?
Yes
No
Surgical History
None
Appendectomy
C-Section
Angioplasty
Bypass
Cataracts
Cholecystectomy
Have you ever had any surgical procedures on foot/ankle or anywhere else on your body?
Yes
No
If yes, please describe:
Do you have any artificial joints?
Yes
No
where?
Do you have an artificial heart valve?
Yes
No
Social History
Do you smoke?
Yes
No
If yes how many packs per day?
1
2
3
4
5
Do you drink alcohol?
Yes, everyday (5-7 days/week)
Yes, occasionally/socially
No/Rarely
Substance abuse:
Yes, I have a current substance abuse problem. P
Yes, I had a past substance abuse problem.
No, I have never had a substance abuse problem
Please specify:
What is your occupation?
Does it involve mostly
standing
sitting
Do you exercise regularly?
No, I do not exercise regularly
Yes, I do the following regular exercise
Family History
Is there any family history (blood relative) of: (Please indicate family member)
Alzheimer’s
Arthritis
Bleeding disorders
Blood clot
Cancer
Cataracts
Circulation problems
Other (specify):
Depression
Diabetes
Emphysema
Heart disease
High Blood Pressure
Neurologica
Strokes
Review of Systems
(Please check the box if you currently have any of these symptoms or check “NONE”)
Cardiovascular
leg pain when walking
fainting
fever
palpitations
chest pain/pressure
vascular disease
leg swelling
valve problems
cold hands/feet
NONE
Genitourinary
blood in urine
decreased frequency
hesitancy
excessive urination
incontinence
kidney disease
increased urgency
kidney stones
NONE
Gastrointestinal
abdominal pain
diarrhea
heartburn
trouble swallowing
blood in stool
decrease appetite
ulcers
increase appetite
constipation
NONE
Integumentary
athletes foot
nail abnormalities
keloids
itchiness
dry, scaly skin
NONE
Hematologic
lower leg ulcers
sickle cell disease
anemia
blood thinners
clotting disorders
NONE
Neurological
tingling
tremors
weakness
paralysis
seizures
numbness
headaches
NONE
Musculoskeletal
back pain
sciatica
joint swelling
joint stiffness
joint pain
muscle pain
joint instability
arthritis
neck pain
NONE
Respiratory
chest pain
shortness of breath
wheezing
emphysema
COPD
coughing
snoring
NONE
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.
Date
Back
Next
Practice:
Today's Date:
Name:
Date
Ethnicity:
Hispanic or Latino
Asian
White
Not Hispanic or Latino
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Black or African American
Declined to specify
Preferred Language:
Pharmacy Name:
Pharmacy Phone:
Pharmacy Address:
City, State, Zip:
Primary Care Physician:
Phone:
Date Last Seen:
Address:
Referring Care Physician:
Phone:
Date Last Seen:
Address:
Privacy Information Preferences
Do you want to be exempt from public reporting?
Yes
No
Can we send mail to the address on file?
Yes
No
Can we call the phone number on file?
Yes
No
Can we leave voicemail on machine?
Yes
No
Will you allow us to send internet based (e-mail) delivery of reminders and newsletters?
Yes
No
If yes, please provide your e-mail address:
*
Who can we leave messages with?
Wife
Husband
Daughter
Son
Other
Name(s):
Current Medications
No Known Medications
I take the following medications;
Name / Dose:
Name / Dose:
Name / Dose:
Name / Dose:
Name / Dose:
Allergies
No Known Allergies
No Known Drug Allergies
Name / Reaction:
Name / Reaction:
Name / Reaction:
Name / Reaction:
Name / Reaction:
Last Flu Shot Date:
Did you get a pneumococcal vaccination?
Yes
No
Have you fallen in the last 12 months?
Yes
No
Were you injured from the fall?
Yes
No
Advanced Directives:
Living Will
DNR
Durable Power of Attorney
Surrogate Appointed
None
PLEASE READ AND SIGN:
The information on my intake form(s) 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 infom1ation listed above. (Assignrnent of Bener11s): I authorize payment of medical benefits to the practice named above. (Release of information I authorize the release of any medical information necessary to process this claim. (Hf PAA Privacy): I acknowledge that I received my HIPAA Privacy Practices Notice. (Medication History): I authorize the Doctor's office to retrieve my medication history.
Patient Signature:
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