Online New Patient Form (2) " " indicates required fields First Name Last Name Date of Birth MM slash DD slash YYYY Address Home Phone Cell Phone City Postal Code Email Occupation Employer Work PhoneCan We Call You At Work Yes No Emergency Contact Emergency Phone Relationship Parent/Guardian Names (if child is under 18) How did you hear about our click to our clinic?Friend/Family/Colleague Friend/Family/Colleague Internet Newspaper Health Care Professional Yellow pages Outside sign Friend/Family/Colleague Internet Newspaper Health Care Professional Yellow pages Outside sign Help us help you! Your foot problems involve: Right Foot Only Left Foot Only Both Feet Why are you here today? Have you sought treatment elsewhere? Yes No Have you ever been treated for or currently suffer with? (check all that apply) Back pain Warts Heel pain High arch feet/pain Corns Callouses Bunions Hammertoes Gout Broken foot/leg bones Flat feet Ankle injury Neuroma Knee pain Ingrown nails Childhood foot problems None What is your current:Height Weight Shoe Size In an average day, how much are you on your feet? 20% 40% 60% 80% 100% What type of footwear do you wear most for work or leisure? Safety shoe/boot Athletic Dress Sandal Other OtherDo you currently use orthotics? (shoe inserts) Yes No Check any sports or activities you participate in regularly Walking Aerobics/Aqua Fit Hockey Racquet Sports Running Golf Soccer Skiing Other None OtherPlease answer the following questions: Do you have or have you ever been treated for? (Check all that apply) Diabetes: Type 1 or Type 2 Heart Trouble Hepatitis Liver Disease Urinary Problem Depression High Blood Pressure Cholesterol Cancer Shortness of Breath Stroke Multiple Sclerosis Heart Attack Skin Disorder Thyroid Problem HIV/AIDS Blood Disease Anxiety Bone Disease Arthritis Epilepsy Tuberculosis Stomach/Bowel Trouble Varicose Veins Circulation Problems None For how long? Other conditions we should be aware ofDo you have any known allergies to? Local anesthetics (e.g. Xylocaine, Novocaine) Yes No Adhesive tape/band-aids Yes No Latex Yes No Other Yes No Allergies OtherAre you slow to heal after cuts? Yes No Do you bruise easily? Yes No Are you currently pregnant or nursing? Yes No Patient Physicians & Medical Specialists: Family Physician Family Physician Phone Please list your current medications (we can photocopy your list) Please Read Please read I agree to the terms I understand that I am financially responsible for all charges, whether covered by my health insurance plan or not. I authorize the Chiropodist to release all information necessary to secure the benefit of payments. I understand that fees for service are payable at the time of service and insurance reimbursement is my responsibility. I hereby give consent for examination and treatment by the Chiropodist and/or anyone working in the clinic authorized by the Chiropodist and allow photographs of treatment areas for the purpose of monitoring. I consent/allow the Chiropodist to send my Physician or health care professional a report regarding my foot exam and treatment plan.SignatureDate MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged.