New Patients - Patient Registration / Medical History

* Required Fields

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Name*:
Date of Birth*:
Address*:
City/State*:   
Zip Code*:
E-Mail:
Occupation:
Home Phone*:
Work Phone:
Cell Phone*:

How did you hear about our office?

Insurance Information

Primary Insurance*:
Policy ID:*
Are you the insured? Yes   No
Subscriber Name:
Relationship to insured?
Insured DOB:
Secondary Insurance:
Policy ID:
Are you the insured? Yes   No
Subscriber Name:
Relationship to insured?
Insured DOB:

Primary Care Physician / Pharmacy Information

Primary Care Physician:
Referring Physician:
Pharmacy Name:
Pharmacy Address:
City/State:   
Zip Code:
Pharmacy Phone:

General Information

Race: (White, Asian, Black, Hispanic, etc.)
Ethnicity: (Hispanic, Not Hispanic)
Preferred Language: (English, Spanish)
Can we call the phone
numbers on file?		 Yes   No
Can we send mail to
address on file?		 Yes   No
Can we send emails to
your email address?		 Yes   No
Who can we leave messages with? Patient    Patient & Spouse    Anyone who answers phone
Allergies*:
(Please write NONE if you
don't have any allergies)
Current Medications*:
(Please write NONE if you
aren't taking any medications)

Medical History
Please check all that apply:

Anemia
Asthma
Diabetes
Hepatitis
Liver Disease
Pacemaker
Thyroid Problem 		Alcohol Dependency
Bleeding Disorder
Fibromyalgia
High Cholesterol
Mitral Valve Prolapse
Phlebitis
Tuburculosis 		Artificial Heart Valve
Chemical Depend.
Gout
High Blood Pressure
Neurological Problem
Psychiatric Care
Ulcers 		Artificial Joint
Circulatory Problem
Heart Disease
HIV+
Osteoporosis
Respiratory Problem
Varicose Veins 		Arthritis
Cancer
Heart Murmur
Kidney Disease
Stroke
Venereal Disease
Other
None

If you check OTHER, please specify:
List all surgeries/hospitalizations:
(If NONE, please write NONE)

Are you pregnant ? Yes   No  
Do you drink? Never   Occasional   Social   Moderate   Heavy   Recovering
Do you exercise? Yes   No
How often do you exercise?
Which activities?
Do you smoke? Never   Former Smoker    Every Day   Some Days
Blood Pressure:
Height:
Weight: lbs.
Have you had a flu shot this year? Yes   No
Why are you seeing
the doctor today?*
Location of pain?
Toe
Heel
Arch
Ball of Foot
Ankle
Leg		 Knee
Hip
Back
Left
Right
Both 		Central
Inside
Outside
Top
Bottom
Nature of the pain?
Constant
Occasional
Sharp
Dull
Aching
 Stabbing
Throbbing
Burning
Shooting
Numbness
What makes pain better? Changed Shoes
Anti-Inflamatory
Decreased Activities
Icing
When is the pain the worst? Morning
Night
When Active
When Resting
When Standing
Onset of the pain? Slow
Sudden
Traumatic
When did the pain start?
What have you tried to help the pain?
Any previous injuries to your
feet, ankles or legs?

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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This form is not intended to report ailments, or to diagnose treatments. Its intent is to request a consultation with Dr. Karen Langone.