Intake Form

 

Please complete the following form and answer all questions.
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Patient Information

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Preferred Phone
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Sex
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If we need to contact you, are we permitted to leave a message on your voicemail?
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Preferred Language
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Have you completed an Advance Directive (living will)?
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Please check your allergies
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Who referred you to our office?




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Is it limiting your activity level?
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Medical History (please check all that apply)






































































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Is your problem related to a Workman’s Comp injury or an auto/other accident?
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Social History

Do you drink alcohol?
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How often?
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Do you smoke, vape or use chewing tobacco?
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Please specify
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Do you have/have had a substance abuse problem?
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Family History

Which family members had the below medical conditions? (father, mother, sibling, etc.)

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Review of Systems

Review of Systems (Check all that you are currently experiencing)
General:
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Head:
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Eyes:
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Ears:
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Nose:
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Throat:
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Cardiovascular:
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Circulation:
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Respiratory:
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Skin:
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Musculoskeletal:
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GI:
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GU:
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Psychological:
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Are you pregnant?
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Are you Breastfeeding?
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Chance of Pregnancy?
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Emergency Contact

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Responsible Party (if minor patient)

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Treatment Consent

The above information is correct to the best of my knowledge. I consent and give my permission for Associates in Podiatry, PC, its healthcare providers, assistants and/or designated replacement to administer and perform such diagnostic procedures, treatments and medical care upon me as they deem necessary. I give permission for photographs of my feet to be taken that are to be kept as part of my medical record. They will not be published as part of medical research or disbursed in any way without my permission. I understand I am responsible for notifying the doctor and/or medical staff of any updates to the information listed above. I give consent for Associates in Podiatry, PC to bill my insurance and collect payment for rendered services.

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