Last Name

First Name

Middle Initial

Todayís Date

Spouse/Parent/Guardianís Name

Spouseís Birthday

Spouseís Employer

Patient DOB

Patientís Age

Residence Address




Marital Status

Single   Married   

Widowed Divorced

Home Phone

Patientís Social Security No.

Driverís License No.

Email Address

Name of Employer & Address


Business Phone

Whom may we thank for referring you?


Name, address and phone of contact in case of emergency


If other than patient, name and address of person responsible for this account

Do you have††††††††††††† Yes

Medical Insurance†††† No

Carrier Name

Subscriber Name

Policy No.

Group No.

Is it through your employer

Yes††† No

Is there secondary insurance?

Yes††† No

Carrier Name


Subscriber Name

Policy No.

List any medical conditions you have (allergies, impairments, etc.)

Name of family physician


Are you currently underYes

Your physicianís care†††† No

If yes, for what

May we contact your physician††††††† †† Yes

For your health records††††††††††††††††††† †† No

Have you had previous††††††† Yes

Treatment by a podiatrist†††† †† No


For What

My chief foot complaint is:

My condition(s) have existed for:





What medicines do you take regularly:

Do you have or have you had any of the following: (*do not know) Are you allergic or sensitive to:
   Yes No DNK      Yes No DNK           Yes No DNK      Yes No DNK
Foot or leg injuries Diabetes        Anemia Novocain
Foot or leg surgery Heart trouble        Gout Penicillin
Foot or leg cramps Epilepsy        Fainting spells Adhesive tape
Foot or leg numbness Liver disease        Bleeder Materials
Knee pain Kidney disease        Blood disease Drugs
Unequal leg length Rheumatic fever        Circulation problems Foods
Weak Ankles High blood pressure        Hardening of arteries Other describe
Bunions Polio        Varicose veins _____________________
Foot skin problems Bursitis        Arthritis _____________________
Toe nail problems Stomach ulcers        Cancer _____________________
Low back pain Asthma        Prone to infection _____________________

I hereby give Dr. _____________________________ permission to examine and treat my feet.

_____________________________________________________ _____________________________________
Patient, Parent, or Guardian's Signature                                            Date