Southernmost Foot & Ankle Specialists

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Foot Pain Identifier

Sports and feet

Foot Products

Foot News

This form is exactly what you would spend time in the waiting room filling out. To better prepare us and to make your office visit quicker, please fill out and submit the form below.

Patient Information
Date:
Social Security Number:
Name:
Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Date Of Birth:
Male or Female:
Marital Status:
Retirement Date:
Drivers License Number:
Drivers License State:
Employer:
Spouse's Name:
Spouse's Employer:
Spouse's Work Number:
Emergency Information In case of emergency contact?
Name:
Relationship:
Home Phone:
Work Phone:
Employer:
Guarantor Information
Name:
Relationship:
Address:
Home Phone:
Work Phone:
Employer:
Referring Physician
Name:
Specialty:
UPIN Number:

Referral Source Check One
Coach:
Coupon:
Direct Mail:
School:
Family:
Family Doctor:
Health Fair:
Screening:
Insurance Book:
Patient:
Radio:
TV:
News Paper:		Which One:
Yellow Pages:		Which One:
Other:

Insurance
Primary Insurance
Name of Insured:
Relation to Patient:
Insurance Company:
Insured ID Number:
Insured Group/Policy Number:
Effective Date:
Insured's Employer:
Secondary Insurance If yes, please provide the following
Subscriber Name:
Birthday:
Social Security Number:
Relationship to Patient:
Insurance Company:
Group/Policy Number:
Effective Date:
Medical History
My Foot Problem is?
How Long?
Prior or Self Treatment for this Problem?
How Long?
Employment Description Check One
Sit at Job:
Stand at Job:
Stand and Walk at Job:
Retired:
Does Employer Require a Particular Type or Shoe?
Boots:
Heels:
Other:

Check Yes or No to Report Family History (Blood Relatives)
	Yes	No	Relative
Diabetes:
Cancer:
Bleeder:
Hepatitis:
Bunions:
Hammertoes:
Flat Feet:
Tuberculosis:
High Blood Pressure:
HIV (AIDS):
Heart Problem/Stroke:
Circulation Problem Leg/Foot:

Check all Condition(s) in YOUR History or YOU Currently Have
Anemia:		Asthma:
Arthritis:		Blood Problem:
Cancer:		Epilepsy:
Fainting Spells:		Gout:
Heart Problem:		Hepatitis:
High Blood Pressure:		HIV (AIDS):
Kidney Problem:		Leg Cramps:
Liver Problem:		Low Back Problem:
Phlebitis:		Poor Circulation:
Prone to Infection:		Shortness of Breath:
Sickle Cell Anemia:		Stomach Ulcer:
Stroke:		Tuberculosis:
Unequal Leg Length:		Varicose Veins:

			Yes	No
Diabetes:		Insulin:

Other:

Additional System Review, Check Other Conditions You current Have
Fever:		Nose/Sinus Problem:
Sore Throat:		Swallowing:
Ear/Hearing Difficulty:		Allergies (Seasonal):
Dizziness/Balance Difficulty:		Fast/Slow Pulse:
"Bleeder"		Chest Pain:
Muscle Pain:		Nerve Pain:
Neurological/Muscular Problem:		Migraine Headache:
Poor Vision/Eye Problem:		Eye Problem:
Glaucoma:		Nervous Disorder:
Anxiety:		Mental/Emotional Problem:
Lymph Gland Problem:		Thyroid Problem:
Hormone Problem:		"Gland" Problem:
Stomach Problem:		Weight Gain/loss:
Skin Problem:		Ulcers/Skin Change:
Sores in Mouth:		Breast Lumps:
Blood in Urine:		Urine/Kidney Problem:
Other:

Click Yes or No and Complete the Following Information
	Yes	No	If Yes, Amount
Do you Smoke?
Do you Drink Alcohol?
Do you Take Any Illegal Drugs?
Heart Valve Implant?
Artificial Hip?
Artificial Knee?
Artificial Other?
Do you Take Medication?			(Include prescription over the counter medications and vitamins)
If Yes, List Name and Dosage.




Name of Your Pharmacy or Drug Store
Pharmacy or Drug Store Phone Number

Check Any Allergies and Complete the Following Information
Adhesive/Tape:		Antibiotics:
Anticoagulants:		Aspirin:
Codeine:		Iodine/Betadine:
Novacaine:		Penicillin:
Seafood:
Other:

	Yes	No
Do you have a problem taking aspirin or ibuprofen?

Please list any significant surgeries you have had within the last 5 Years
	Date:
	Date:
	Date:
Please list other significant hospitalizations you have had within the last 5 years.
	Date:
	Date:
	Date:

What is your Height?

Weight?

	Yes	No
If Female, could you be pregnant?

Name of family doctor?
Date of last exam:


Office you are visiting:
Email Address:
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Other Message:

Contact one of our locations near you to make an appointment
Kendall - Homestead - Ocean Reef - Tavernier - Marathon
Big Pine Key - Key West

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