Privacy Policy                 New Patient Information           Referral Form

NEW ENGLAND PODIATRY

Patient Name:___________________________                                                      Date:________________

MEDICAL INFORMATION
This information is important for our records and your health!!

Briefly describe your  foot problem:       ___________________________________________________________________________________ ___________________________________________________________________________________ ______________________________________

How long has it been bothering you?______________________________________

Any past problems with your feet or ankles?  Surgeries or Injuries?_____________________________________________________________________________ ________________________________________

Shoe size_______  Weight_______  Height______
 

GENERAL HEALTH INFORMATION

Do you have diabetes?  Yes____ No____   # of years?______      Do you take Insulin?  Yes____ No_______

Do you have circulation problems?  Describe:_________________________________________________________________

Have you had any major or minor surgeries?  Describe:____________________________________________________________________________ ___________________________________________________________________________________ _____________________________________

Last visit to Primary Care Physician:_____________ May we contact your physician about your health?___________________

What medications do you take?_______________________________________________________________________________ ___________________________________________________________________________________ _________________

(  ) Take Antibiotics prior to dental work ___yes ___no

ALLERGIES/SENSITIVITIES TO MEDICATIONS (circle problem items)

(   )  NONE

Adhesive Tape    Advil    Aspirin    Betadine    Codeine    Epinephrine    Iodine Local Anesthetics (Novocaine/Lidocaine) 

Morphine   Penicillin   Sulfa Drugs Other:__________________________________________________________________

MEDICAL HISTORY (Check any of the following that apply)

(  ) NO MEDICAL PROBLEMS

(  ) Anemia  (  )Arthritis type _____________ (  )Artificial Joints (  ) Asthma  (  )Bladder
(  )Cancer___________
(  ) Gout  (  )Frequent Infections (  )Healing  (  )Heart  (  )Heart Valve Implant  (  )High Blood Pressure
(  )High Cholesterol (  )Hormone  (  )Intestine  (  )Kidney  (  )Liver  (  )Lung  (  )Neurologic Disorder  (   ) Reflux   (  )Rheumatic Fever (  )Skin  (  )Stomach Ulcer  (  )Tuberculosis  (  )Weight Loss  
(  ) Other_________________________________________.

                                                                                                              _____________DPM Date_______

Patient Name:_________________________________

FAMILY HISTORY

(  )Bleeding Disorder  (  )Bunions  (  )Cancer describe__________________ 
(  )Circulation Problems  (  )Clubfeet  (  )Diabetes  (  )Flatfeet  (  )Hammertoes
(  )Heart Disease  (  )Neurologic Disorder  (  )Osteoarthritis  (  )Rheumatoid Arthritis  (  ) Stroke

SOCIAL HISTORY
Do you smoke?  ____yes ____no  #packs per day_____ 
Previously smoked ____yes _____no  # of years____
Do you drink alcohol ____yes ____no   () light usage   () moderate usage   () heavy usage
Employment:   ( ) sit at work   ( ) stand at work   ( ) walk at work   ( ) retired   ( ) disabled

Signature_____________________________________    Date____________________

                                                                                                              _____________DPM Date_______

NEW ENGLAND PODIATRY PATIENT INFORMATION
(PLEASE PRINT)

PATIENT NAME__________________________________TODAY'S DATE_______________________

ADDRESS_______________________________________CITY_________________STATE____ZIP___

HM. PHONE____________________WK.PHONE______________________FAX #_________________

E-MAIL ADDRESS________________________________

 SEC. #_________________________________________

MARITAL    S     M    W           SEX                           AGE                       
STATUS       D    SEP.              M     F                                           
DATE OF BIRTH:_______/_______/__________

PERSONAL  PHYSICIAN____________________________________________________________
ADDRESS______________________________________________PH# _________________                                                                                                              

PHYSICIAN'S E-MAIL ADDRESS
 (IF YOU KNOW IT)_________________________________________________

PHARMACY NAME:______________________________PHONE#___________________________

WHO WERE YOU REFERRED BY?______________________________________________________

SPECIALIST

NAME:_(Surgeon, Rheumatologist etc.)__________________________ADDRESS________________

PATIENTS
EMPLOYER______________________________POSITION_________________________________

BUSINESS
ADDRESS________________________________________________________________________

SPOUSE'S NAME__________________________________________________________________

SPOUSE'S EMPLOYER______________________________________________________________

SPOUSE'S WORK PH (__________)   _______________                           ______                                         

PERSON RESPONSIBLE FOR BILLS (IF OTHER THAN ABOVE)

NAME_________________________________RELATIONSHIP________________________________

ADDRESS:_________________________________________________________________

PHONE NUMBER:____________________________________________________________

EMPLOYER___________________________POSITION_____________________________________

BUSINESS ADDRESS_________________________ ________ ______________________

BUSINESS PHONE___________________________________________________________

INSURANCE INFORMATION

TYPE OF INS              INS HOLDER'S NAME           INS HOLDER SS# OR INS ID#                RELATION TO PT     

1._________________________________________________________________________________

2._______________________________________________________________________

NEAREST RELATIVE TO NOTIFY IN AN EMERGENCY

(IF NOT ALREADY LISTED)

NAME____________________________________________________________________

RELATIONSHIP_____________________________________________________________                                                                                      

ADDRESS_________________________________________________________________

HOME PHONE# (         )_______________________________________________________

BUSINESS PHONE# (         )____________________________________________________

AUTHORIZATIONS

BENEFITS TO PHYSICIAN:

I HEREBY AUTHORIZE PAYMENTS DIRECTLY TO THE PHYSICIAN FOR MEDICAL AND/OR  SURGICAL BENEFITS.

I  UNDERSTAND THAT I AM RESPONSIBLE FOR ANY PORTION OF MY BILL NOT COVERED BY MY INSURANCE COMPANY.

I ALSO UNDERSTAND THAT IF MY INSURANCE REQUIRES A REFERRAL, I WILL OBTAIN ONE, OR I WILL BE BILLED IN

FULL FOR MY VISIT.

RELEASE OF INFORMATION:

I HEREBY AUTHORIZE RELEASE OF INFORMATION FOR INSURANCE CLAIM PURPOSES.

THE INFORMATION AUTHORIZED FOR RELEASE MAY INCLUDE INFORMATION WHICH MAY BE CONSIDERED A COMMUNICABLE OR VENEREAL DISEASE, INCLUDING HEPATITIS, SYPHILLIS, GONORRHEA, HIV AND AIDS.

I consent to foot/ankle xray photographs which may become part of my permanent record and/or sent to other physicians and insurance companies as may be needed for my care.

I understand all of the above and hereby state that the information is correct to the best of my knowledge.

SIGNED________________________________________DATE________________________

©2003 New England Podiatry      webmaster     Last updated: 04/29/03