New Patient Packet - Sanicola Podiatry Associates

Sanicola Podiatry Associates 372 Mill
Street Hagerstown, MD 2L7N
3OL.79O.227A
WELCOME
city:_
PATIE{TINTOR&TATION
state:_
Phone (
Name:
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I prefer to be called:
Employer
Address:
Occupation
City:
Work Phone
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Work Phone (
Cell Phone (
Home Phone
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INS:I'RAI{CE INTORMATION
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Primary lnsuranco
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Grp #
Date of Birth:
Name of
Social Security Number:
cender:
Maritat
Status:
Date of Birtrl
I-l remate flur"r"
patient
Relationship to
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Name of Employer:
Occupatlon
Primary Care Physician
Phone #
OcqIpation:
Address:
emergencyfrr'ac
State:-
City:
Home
Phone:
Work
RESPONSIBI.E
Relationship to
Patient
I
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spouse
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PATIENTS UNDER 18
Name
Relationship ro
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Address:
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Patient Signature
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Accompanlng Adults Name:
Signature
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or PaGnt or Guardian
?RTVACYPOUCY
Notice of Privacy Prastices Acknowledgement
{Patients Name), acknowledge that I have been provided wth the HtppA Notice of pdvacy
Practices.
Patient Signature
c-t3-
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Pain/Conditionaggravatedby:
nAnyweightbearing
l-l Running
I sooping
n Pr".rur" from jumpinil
l-lst nOing
f]w"ning
n Exercise
I
foot l-l
nrin
rising
upon
I
f]
l-l
pr"*rur"
ro batr of
Benoing
pr*r*ure irom shoes
can upon resting
I}"\4ILY HISTORY
l'lease
Arthritiq
f]
Siabelcs
Irrtl"t
raurer
f]uott"r. n crunopur"nt l-l sinring
[uotner l-lcranoparent l-lsintrnr:
Srore Iruti,"r" [n,totn",
$l-clle-celAnemia
Deceased
fra*
Irrt"t
what
iftdiia$ lo yau lamtly tned$a! hisary
callrer
il0art-D-lsea$e
l-lsiolng
[-lrather f]r,tot'er l-lcrandparenr
l-lrrtn",
l-luo$rer [-lGrandparent
$--l-ut
IFather [Mother IGrandparent ISiUting
G[N[RAI. MEDICAL HISTORY
Place
[-l
l-l
a check matk next
AttergieslHay,fever
n
Di"b"t",
Rnemia
l*l
Gastrointestinat [)is0;,lis
to any af the follawing thal pertain to
fl
f]
wur medical history
Liver Disease
lo*
Btood Pressure
l-l Poor circutation
I-l Respiratory Disease
Innxiety
Ioout
f]*tn'iti*
f]
xea.t Disease
f
I
nsmma
[-l
Hepatitis
I
eeeoing Disorder
fl
nign Btood Pressure
l-l s"t.r,.uu
I
Nrv
flsro
flst ox"
I
I
I UIOOO
lranstustons
Btooo Cto(s)
[-l crn.",
[*l cnest pain
[-l Depression
Isinrng
l-lrur,",. f]r,aor,er f-lorandparent l-lsinnng
f]raotner [-lGrandpa.ent f--lt;ir,r,nr; lunerculasls- nrutnu." [naother [lGrandparent Isioring
l*lcrandparenr
f,
l-l
[-l
l-l
Hign cholesteror
lnlury
loint
pain
Rh.u*rt"
Feu*l.
[-l
tnyroio Disease
I
Tuoercutosis
no*ur---
Kidney Disease
I"\ST SURGERJES
Plaxe a check
X ,o prior surgical history
f-l aneurysm Repair
[l Appendectomy
l-l BacldNecr Surgery
l-l Btadder Suspension
l-l cancor surgery
[-l Cardiac Surgery
l-l Carotid Endarterectomy
ma*
nexl lo any af t)6r lollowrng lhat pedain to your medicat histoty
l-lCurpo,
lurrnei Surqory
l*l Catarn,: I 13i,ry
IGutt utr,i,r,r,
-i1
f
1
HysterBctomy
f]
xn"u surgery
l*l Pacemaker
[-l snoulder Surgery
nar:
[*l
[-l
Foot,.i,,rr;,;ry
n
SinusiNasat Surgery
uernia
f-l
Steritization
l-l
Hip
I
rnyroiu
Re
ptac;c,rrent
Iotr,.,
IIOSHTAUZA'UONS
Please list Hospitalizatons not including Surgeries?
Tl
f
sioting
LANGUAGE
(ACl
Race:
[-l
[
I
f
Anrerican tndian orAlaskan Nalrvt:
ruruue Hawaiian or pacific l$]ander
n.irn
I
wnir"
Iotn",
ancx or African American
ETHNICITY
E$rnicity:
I
[--l
Htpanic or Latrno
Not Hirprnic or Latrno
TOBACCO USE
Smokrng
Status? [-l
Cunent Smoker every
day
l-lCr.irrentsmot<ersomedays
lf yos, how nrany packs per day:
f
Fo,nrsrgrn6k6l
how many years;
f]NeverSmoter
TooaccoUser:
l-lyES fl*O
MEDTCAfiONS
(INCLUDE PRESCRIPTIONS, OVER THE COUNTER & V|TAM|NS)
ALLERGIES
fl
No
[*l
Adnesiveriape
uo*n
(II.{CLUDE FOOD Ar.rD
PIANI)
allergy history
nAnti-coagulant
[*l
l-l
l-l
Rspirin
flcoo"in"
f-l cortiron"
Demerot
f]
totiine
l-l r,,,,
flPeniciilin
surroo
|.l
f-l
Isrit"
Iotn"'
Nouocain
f]
iocat Anestiretic
trythromycin
CIIIETCOMPI{NT
Siros 5;.a
Occu0alion
What is the chief complaint for which you came to b€ tr*ated?
Howwould you describe yourpain on a scale of 'l to
Describe your pain:
l-l
Sharp
Ieumtns
Ili',.
Incni,,g
I-l
Have you ever been to a Podiatrist
-
before?
l-l
yes
l-l
No
ttyes, when
l*l lnror:i:ing [-l snooring I
aectricat Sensation
f]
rinr & Needles
I
s-z oryu
[-l t-3 weet<s
l*l
s-o weet<s
n
6-a weet<s
[-l
o-9 montns
l-19-tz
[-l
greater than
Numbness
Location of pain or primary complainl
How long has your problems been present:
Onset of condition or
l*l t-3 oryu
f] 36 nrr.:rrtns
injury: flOraOuat onset
ove r
tifi're
i-l
monr'rs
Su.i,t*n orrset from activity or injury
1
year