123 Fenton Foot Care- 14229 Torrey Rd. Suite 1 Fenton, MI 48430 To Submit Prior to Appointment, Send Via fax, 810-629-9243 or email info@fentonfootcare.com Patient Last Name* Patient Legal First Name* Middle Initial* Section BreakPatient Date of Birth* MM slash DD slash YYYY Patient Social Security #* Last 4 Digits OnlyGender* Male Female Marital Status* Single Married Other Section BreakAddress (No PO BOXs) :Street*City* State* Zip* Section BreakHome Phone*Cell Phone*Email* Section BreakOccupation* Employment Status* Full Time Part Time Retired Unemployed Student Employer* Section BreakEmergency Contact Name* Relationship Spouse Parent Best Phone Number*Section BreakFamily Doctor* Office Phone*How did you hear about our office?* Section BreakWhat brings you in today (be specific)* Duration* Is this Auto or Work-Comp related? No Yes Date of injury if Auto related or Work-Comp? MM slash DD slash YYYY If the injury is related to an auto accident or a worker's compensation injury, please provide the injury date.Section BreakInsurance Carrier Primary Ins. Carrier* Name of Policy Holder* Policy Number* Policy Holder DOB* MM slash DD slash YYYY Section BreakSecondary Ins. Carrier Name of Policy Holder Policy Number Policy Holder DOB MM slash DD slash YYYY Section BreakMedicare Patients Only Are you enrolled in Hospice Yes No Do You receive Home Health Care Yes No Do You live in a Nursing Home Yes No Section BreakPrivacy Information Where may we contact/leave you message(s)Home Yes No Cell Yes No Name of person(s) who can access your records/PHI or pick up records.First & last name and relationship: First & last name and relationship: First & last name and relationship: Section BreakAttest Accept term*I do hereby attest that this information is true, accurate and complete to the best of my knowledge. understand that any falsification, omission or concealment of any material fact may subject me to all fees for services and/or other liability. I also understand that I am to notify Fenton Foot Care immediately of any changes to the above information and annually upon the office’s request. I also acknowledge that I have been provided the opportunity to take and review the office’s HIPAA Policy, Authorization from Patient or Legal Representative, and Notification of Office Policies and Procedures (version01-01-2017). (Available in our waiting room and/ or by request). I further acknowledge and accept all the terms and conditions outlined in all forms listed including “notifications of office policies and procedures”, “HIPAA policy notice of privacy practices”, and “authorization from patient or legal representative”. I authorize Fenton Foot Care to contact me via text and email. (MSG & date rates may apply) I Agree Attest to submission* By typing in your full name in this field you are agreeing to the terms and conditions related to the online submission of your information.Terms of agreement date* MM slash DD slash YYYY Date of the agreement to term of online submission of patient information. Current Medical History Patient Shoe Size* Please provide shoe sizeWeight*Height*3'4’5’6’FtInch*01234567891011InchAre you Diabetic Yes No Physician that follows your diabetic care* Date last seen by them* MM slash DD slash YYYY Section BreakCurrent Conditions - Mark NONE if the condition below does NOT apply to youSymptoms :* None Chills Fever Nausea Vomiting Neurological :* None Numbness/Nerve Pain Seizures Strokes Skin :* None Cellulitis/Infection Fungal Nails Ingrown Nails Sores Rash Warts Vascular :* None NoneLeg/Calf Cramping Cold Feet Leg/Calf Cramping at rest Skin red/ Pale/ Purple Section BreakAllergies Allergies None Mark NONE if the allergies below do not apply to youAllergies DetailsSection BreakCurrent MedicationsDo you take any medications?* NO YES If you take any medication, please fill out the section below.Medication List can be copied & attached separately if available - You do NOT have to Rewrite medicationsCurrent Medication ListMedicineDosageHow Often Section BreakPharmacy you prefer to usePharmacy* Location* Zip* Section BreakPast Medical HistoryPlease added important medical history itemsSocial HistorySmoking History Non Smoker Current Smoker Former Smoker Packs per day Years of Cessation Family History Peripheral Artery Disease (PAD) Questionnaire and Fall Questionnaire Do your legs ever feel tired causing you to stop and rest?* Yes No When you walk do you ever have to stop because you have pain or cramping in your calves or thighs?* Yes No Do you ever experience cramping, tightness, "Charlie Horses" or pain in the legs or feet when lying down that improves when you stand up?* Yes No Do you have any wounds, cuts, or sores that are not healing on your feet or toes?* Yes No Is the skin on your legs or feet pale, Reddish or purple?* Yes No Is the skin on your legs or feet cool to the touch?* Yes No Have you ever been told you have diabetes? even borderline diabetes?* Yes No Has anyone ever told you that you have poor circulation in your legs, untermittent claudication or peripheral arterial disease?* Yes No Have you ever had any testing done to your legs for these diseases?* Yes No Section BreakDo you use a walker, cane, or other assistive device when walking?* Yes No Do you feel unstable when you walk?* Yes No Have you fallen in the past, or had a "Near fall" in past?* Yes No I Agree Terms and Conditions Search for: Type then hit enter to search By continuing to use this website, you consent to the use of cookies in accordance with our Cookie Policy. 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