PATIENT DEMOGRAPHICS

Intake Form

Please fill out the following form.

First name

Last name

Email

Main Phone

Are Texts ok?

No

Yes

Secondary phone number?

Are Texts ok?

No

Yes

Date of birth

Month

Day

Year

Gender at Birth

Male

Female

Address (Apt# too?)

Home type? House, Apt, Indep. Living, Asst'd. Living? (Not Nursing Homes)

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 and 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.

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.

Intake Form

Intake Form

Travel Fee:

Travel Fee:

Please fill out the following form.

Date of birth*