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Phone: (737) 231-1087 Fax:(833) 629-0523

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PATIENT DEMOGRAPHICS

Intake Form

Please fill out the following form.

First name*

Last name*

Email

Main Phone*

Are Text ok?

No

Yes

Secondary phone number?

Are Text ok?

No

Yes

Date of birth*

Month

Day

Year

Gender at Birth

Male

Female

Address

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?

Member ID *

Group ID

Secondary insurance name?

Member ID

Group ID

What foot condition would you like treated?

Medical 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

Separated

Do you Smoke?

Yes

No

If former smoker, duration and year that you quit:

Do you drink alcohol?

Yes

No

If you drink alcohol - 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.

Austin Podiatry House Calls

Phone: (737) 231-1087

Fax: (833) 629-0523

OPENING HOURS

Monday through Friday. Closed on US and School holidays.

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