New Patients - Patient Registration / Medical History

* Required Fields

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Patient Name*:
Preferred Pronoun:
Date of Birth*:
Address*:
City/State*:   
Zip Code*:
Alternate Address  
Local Address:
City:
State:
Zip Code:
Phone Number*:
Primary Care Physician*:

Medical History

Insurance Company:
Account Number/ID:

Allergies*:

None Known
Allergies to Medication
Anesthesia
Foods
Tape
Latex
Shellfish
Iodine
Other

Please check all that apply:

Acid Reflux
Anemia
Arthritis
Asthma
Artificial Joints
Abnormal Bleeding
Back Problems
Blood Clots
Blood Transfusion
Bronchitis/ Emphysema
Cancer
Pre-Diabetic
Diabetic
A1C:
Blood Sugar:
Fibromyalgia
Gout
Heart Attack
Heart Disease/ Failure
Hepatitis
HIV+ / AIDS
High Blood Pressure
High Cholesterol
Kidney Disease
Liver Disease
Low Blood Pressure
Migraine/ Headaches
Mitral Valve Prolapse
Neuropathy
Open Sores
Pneumonia
Polio
Rash
Rheumatic Fever
Sickle Cell Disease
Skin Disorder
Sleep Apnea
Stomach Ulcers
Stroke
Thyroid Disease
Tuberculosis

List ALL Medications:
Surgical History:
Hospitalization History:

How long ago did the pain start?
(Days/Weeks/Months/Years)
Onset of the pain? Gradually developed over time
Began all of a sudden
Nature of the pain?
No Pain
Sharp
Dull
Aching
Burning
Radiating
Itching
Stabbing
Other
Rate your pain on a scale of 0-10:
(0 - no pain, 10 - worst pain possible)
Since the time your pain or problem began, has it: Stayed the same
Became worse
Improved
What makes the pain or problem worse? Walking
Standing
Daily
Activities
Resting
Dress Shoes
Closed Toe Shoes
Running
Other
What makes pain better?
Current Problem  
What specific symptoms bring you to our office today?
What are you seeking help for?
Location of pain?
Toe
Heel
Arch
Ball of Foot
Ankle
Leg
Knee
Hip
Back
Left
Right
Both
Central
Inside
Outside
Top
Bottom
Social History  
Marital Status: Single   Married   Partnered   Separated   Divorced  Widowed
Use of Alcohol: Never   No Longer Using   History of Alcohol Abuse  Rare   Occasional   Moderate   Daily
Use of Tobacco:  Never   Quit - How Long Ago?    Smoke - How Long?
Use of Recreational Drugs:  Never   Quit - How Long Ago?  Type?
Current Use - Type? Rare   Occasional   Moderate   Daily
Occupation:
Exercise:  Never Rare Occasional Weekly Several Times a Week Daily
Types of Exercise:
Family History  
Do you have a family history of:
Diabetes
Cancer
Heart Disease
High Blood Pressure
Stroke
Coronary Artery Disease
Thyroid Disease
Rheumatoid Arthritis
Other

Electronic Signature - ASSIGNMENT AND RELEASE*

I, the undersigned, certify that I (or my dependent) have insurance coverage with the company listed above and assign directly to Dr. Langone all insurance benefits. If any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submission.

I certify that the above information is true and correct to the best of my knowledge. I give my permission to the doctor to administer and perform such procedures as may be deemed necessary in diagnosis and/or treatment of my feet. I understand that there is a $40 fee if I do not give 24 hour notice for cancellations.

I understand that I am responsible for notifying the doctor and/or medical staff of any updates to the Information that I provided. I authorize the Doctor's office to retrieve my medication history. I acknowledge that I received my HIPAA Privacy Practices Notice.

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