New Patient Form - Fusion Foot and Ankle

New Patient Intake Form
Patient Information
Name *

First Name Middle Name Last Name
Gender *
Date of birth *

Month Day Year
Date
Social security number *
Email
example@example.com

Address *

Street Address
Street Address Line 2
City	State
Zip Code	Country

Phone number *
Phone #
Family Physician and City *
Pharmacy's Name and City *
Name of Employer and City
How did you hear about us? *
Doctor's name
PLEASE TAKE A PICTURE OF YOUR DRIVER'S LICENSE
EMERGENCY CONTACT INFORMATION
First and Last Name *
Relationship to you *
Emergency Phone Number *

Area Code Phone Number
REASON FOR VISIT
Reason for visit *
Where does it hurt? *

Right Foot Right Ankle Left Foot Left Ankle
How long have you had this problem for?
Severity of pain *

None Mild Moderate Severe Severe at times
Type of pain (if any) *

Sharp Dull Stabbing Aching Burning
This problem is *

Improving Worsening Unchanged
What makes it worse? *

Activity Exercice Work Laying in bed
What makes it better? *

Rest Ice Heat Elevation
What treatments have you tried?
Medical History
Medical history - Please check all the ones that apply to you *

None Diabetes type 1 (with insulin) Diabetes type 2 (no insulin) Arthritis High Blood Pressure Stroke (CVA) Heart Trouble Kidney Disease Lung Disease (COPD) Hepatitis (A, B, C) Stomach Problems Anxiety / Depression Gout Fibromyalgia Blood Clots - DVT Artificial Joints Cancer HIV / AIDS
SOCIAL HISTORY
Past Surgeries
Do you smoke tobacco? *
Do you drink alcohol? *
FAMILY HISTORY
Check all that applies to your family members *

Gout Diabetes Flatfeet Bunions Cancer Blood clots None
REVIEW OF SYSTEMS

Please check all the ones that apply
Nerve: *

Foot Burning Foot Numbness Seizure Loss of Balance None
Skin: *

Rash Skin Sores Itching Dry Skin Toenail Changes None
Orthopedic: *

Joint Pain Muscle Pain Leg Cramps Weakness Knee Pain Back Pain None
General: *

Fever Chills Nausea Vomiting None
MEDICATIONS

GIVE A LIST OF YOUR MEDICATIONS WITH THEIR DOSAGES
If more than 6 meds, please bring the complete list to your 1st appointment.

Name

Dosage

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5

Medication #6

Allergies *
FINANCIAL
*

Insurance No insurance - Cash
INSURANCE INFORMATION

Primary Insurance
1) Please take a picture of the front of your insurance card
2) Please take a picture of the BAck of your insurance card
Name of insurance plan as written on card *
Policy # / Subscriber ID # : *
Relationship: *
Name of Policy Holder: *

First Name Last Name
Policy Holder Date of Birth: *

Month Day Year
Date
INSURANCE INFORMATION

Secondary Insurance
Policy # / Subscriber ID # :
Relationship:
Name of Policy Holder:

First Name Last Name
Policy Holder's Date of Birth:

Month Day Year
Date
PLEASE SEE THE NOTICE OF PRIVACY PRACTICES BELOW
I give permission to Moody Mankerious, DPM to examine/treat me during the care of my condition. I understand that I am financially responsible for all charges, whether or not paid by insurance. The only limitation to my financial liability for charges not paid by insurance occurs in the event of contractual limitations to the charged fees that have been agreed upon by Moody Mankerious, DPM and the insurance company. I authorize use of this signature for all insurance claims (including Medicare/Medicaid if applicable).
- I understand that there is a $25 fees for no shows, cancellation/rescheduling done later than 24 hours prior to the appointment time.
Balance payment:
- I agree that any balance less than 50$ will be directly taken out from the credit card saved to my account.
- I agree that any balance over 50$ will be charged a 5% interest if not paid within 30 days.
Signature *

Clear
Date of Signature *

Month Day Year
Date
Should be Empty:

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New Patient Intake Form

Patient Information

EMERGENCY CONTACT INFORMATION

REASON FOR VISIT

Medical History

SOCIAL HISTORY

FAMILY HISTORY

REVIEW OF SYSTEMS

MEDICATIONS

FINANCIAL

INSURANCE INFORMATION

INSURANCE INFORMATION