12 Fenton Foot Care- 14229 Torrey Rd. Suite 1 Fenton, MI 48430 To Submit Prior to Appointment, Send Via fax, 810-629-9243 or email [email protected] 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* 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 BreakPrivacy Information 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’FtInches*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 HistoryPast Medical History - mark NONE if the history below does NOT apply to you NONE AIDS/HIV Abnormal heart beat Anxiety Asthma Bleeding disorder Blood clot CAD Chronic back pain Chemotherapy Circulation problems Dementia Depression Diabetes Gastric reflux Glaucoma Gout Heart attack High cholesterol High blood pressure Kidney disease Liver disease Lung disease Multiple sclerosis Neuropathy Osteoarthritis Parkinson's disease Rhheumatoid arthritis/autoimmune disease Seizures Skin disease Stroke Thyroid disorder Ulcers/Sores Other If you have or have had cancer, please provide the type Do you have Hepatitis, and so so what type? If "Other" was selected above please provide more information. Family HistoryAdditional family history for your mother and father. Please check all boxes that apply.Mother* No significant family medical conditions Unknown family history Diabetes Heart Attack Cancer Other If Other is selected provide additional Mother information Father* No significant family medical conditions Unknown family history Diabetes Heart Attack Cancer Other If Other is selected provide additional Father information Please added important medical history itemsSocial HistorySmoking History Non Smoker Current Smoker Former Smoker Alcohol History None Social Occasional Heavy Packs per day Years of Cessation
