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Intake Form
Travel Fee Calculator
Please fill out the following form.
First name
Last name
Email
Main phone
Are Texts ok?
No
Yes
Secondary phone
Are Texts ok?
No
Yes
Date of birth
Gender at birth
Male
Female
Client address (see travel fee calculator above)
Apartment number?
Home Type
Referring Source Name and Contact Information:
On hospice care? If yes, name of supervising physician and last hospice nurse visit date?
Primary Physician Name and Contact #?
Primary Physician / Practitioner last visit date within the last 6 months? (This is an insurance requirement.)
Preferred pharmacy name and phone number?
Primary insurance name? (If on hospice, this is Medicare.) Let us know if you have an Advantage plan. PPO? HMO? HMO's need referrals and authorization codes.
Member ID
Group ID
Secondary insurance name?
Member ID
Group ID
What foot condition would you like treated?
Medical History / Diagnoses?
Medications?
Food and Drug Allergies?
Family Medical History. List family members and a few medical conditions they have had.
Marital Status
Married
Single
Widowed
Divorced
Seperated
Do you smoke?
Yes
No
If former smoker, duration and year that you quit:
Do you drink alcohol? If so, how often? Amount?
Do you exercise? if so how often
A little
No
Moderate
More than most
Do you use any device to walk?
No
Walker
Cane
Wheelchair
Surgical History
Language
English
Spanish
Other language?
Constitutional symptoms (fatigue, appetite & weight changes)
Eyes (blurry vision, eye problems)
Ears, nose, mouth, throat (hearing loss, ear pain, nose/mouth/throat problems)
Cardiovascular (chest pains, rapid heart rate, palpitations)
Respiratory (shortness of breath, wheezing,cough)
Gastrointestinal (stomach/intestinal pain, constipation,nausea, vomiting, heartburn)
Genitourinary (increased frequency, incontinence, urgency, pain)
Musculoskeletal (joint pains, stiffness, arthritis, swelling, weakness)
Integumentary (skin rashes, lesions, dryness)
Neurological (numbness, burning, tingling, paralysis, drop foot)
Psychiatric (anxiety, depression, dementia, agitation, memory loss)
Endocrine (ex: thirst, sugar imbalances, temperature intolerance)
Hematologic/Lymphatic (blood thinners, clotting issues, bleeding, bruising)
I declare that the info I've provided is accurate and complete. *
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