Faca face sheet 2 (4) (1) (1).xls

FOOT & ANKLE CLINICS OF AMERICA
PATIENT REGISTRATION FORM
PATIENT PERSONAL INFORMATION
Last Name First Name MI
__ American Indian/Alaskan Native __ Asian __ Black/African American __ Hawaiian/Pacific Islander __ White __Other Shoe Type: __ Dress __ Work Boot __ Steel/Ceramic Toed PATIENT CONTACT INFORMATION
Home
PATIENT HEALTH SERVICES INFORMATION
Primary Care Physician Name:
___ Result of Auto Accident ___ Result of Injury while at Work Workman's Comp Claim #: ___________________________ How did you hear about our practice: ___Google ____Zoc Doc ____ Phone Book ___ Insurance Company ___ Sign/Location ___ Physician Referral ____ Friend/Family Name:_______________ Other:__________________________ FOOT & ANKLE CLINICS OF AMERICA
PATIENT REGISTRATION FORM
PATIENT INSURANCE INFORMATION
Primary Insurance Information
Secondary Insurance Information
PATIENT MEDICAL HISTORY
Medical history:__ Diabetes___# of years __ Renal Disease__ Dialysis __ Heart Disease __ Stroke __ Heart attack __ HIV __ Dementia
__ Hypertension __ High Cholesterol __ Sickle Cell __ Varicose Veins __ Hepatitis __ Neuropathy __ Arthritis __ Gout __ Blood Clots Please specify any other medical conditions: Allergies: __ None __ Penicillin __ Sulfa __ Codeine __ Iodine __ Latex __ Local Anesthetics __ NSAIDS __ Aspirin __ Food
Reaction type: ____________________________________________ Medications and Vitamins Please List:
Are you currently taking: __ Coumadin __ Plavix __ Pletal __ Lovenox __ Aspirin Past Surgeries: __ None __ Appendectomy __ Tonsilectomy __ Hysterectomy __ Stents __ Bypass Procedures __ Arthroscopy
__ Knee replacement __ Hip Replacement __ Back Surgery __ AV fistula __ Transplants __ Varicose Veins __Fracture Repair Other: _________________________________________________ Complications: __ Problems with anesthesia __ Blood Clots Family History: __Heart Disease __ Stroke __ Diabetes __ Cancer __Rhematoid Arthritis
Social History: Do you use the following for ambulation: ___ Walker ___ Cane ___ Wheel Chair ___ Brace ___ Prosthetic
Tobacco: __ None __ Current __ History of Use # of Packs per day:______ # of years: ______ When did you quit: _______ Alcohol: __ None __Current __History of abuse # Drinks per week: _____ Recreational Drug Use: __ None __ Current __ History of Use When did you quit:_______ What type:_____________
Exercise Activities: __ Walking __ Running __ Bicycling __ Weight lifting __ Elliptical __ Swimming __ Yoga/Pilates Other: ________________________ # times per week: ______________________ Living Situation: ___ Alone ___ Nursing Home ___ Caretaker ___ Family Other:____________ I hereby give my permission to the physician of Foot & Ankle Clinics of America to administer any non-surgical treatment that maybe necessary to treat my foot condition. I understand that I am financially responsible for all charges (whether or not covered by the insurance company). I understand it is my responsibility to be knowledgeable about my insurance plan and it's coverage. I understand that if I receive a check from my insurance company for services provided by Foot & Ankle Clinics of America, I am responsible for paying Foot & Ankle Clinics of America immediately. Co-Payments must be paid at the time of service.
Signature: _________________________________________________________________________ Date: _________________________ I authorize the release of any medical information necessary to process my insurance claim. I authorize payment of Medical Benefits to Foot & Ankle Clinics of America, LLC (must sign prior to treatment). We need copies of all Insurance cards/Driver's License/State ID
Signature: _________________________________________________________________________ Date: _________________________

Source: http://www.footexperts.com/public_html/pdf/2012%20Patient%20Registration%20Form.pdf