BRAD BACHMANN, DPM  ***  MICHELLE STERN, DPM  ***  AMY WALSH, DPM

WELCOME TO OUR OFFICE

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Patient Information

Name: ______________________________________ Date of birth: ____________ Age: _____
Address: _________________________________________ City: ___________________ Zip: ________
Home phone: _________________ Work phone: _________________ Cell phone: _________________
Marital status (circle one): S M W D Sex: M F SSN: ____________________ Shoe Size: _____
If patient is a student, name of school/college: _____________________ Full-time ____ Part-time ____
Whom may we thank for referring you? ____________________________________________________
What is your present foot problem? ________________________________________________________
If injured, give date and explanation of how injury occurred: ____________________________________
_____________________________________________________________________________________
Name of family physician: _______________________________________________________________
Name of former podiatrist: ______________________________________________________________

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I have read all information and answered to the best of my ability. I understand and agree that regardless
of insurance status, I am ultimately responsible for all services and charges incurred. I have read all
information provided to me regarding health and finances and understand my responsibility as a patient.
I certify that all information I have provided is current and factual. I will notify you of any changes in the
above information.
Assignment and release: I hereby authorize my insurance benefits to be paid directly to my physician and
I am financially responsible for noncovered services and supplies. I also authorize the physician to release
any information required to process this claim.

Signature of patient or parent/guardian _______________________________________

Printed Name ________________________________________

Date _____________

 

Health Information:

Are you in good health? Yes No
Are you or have you ever been under a physician's care during the past two years? If yes, why? Yes No
Are you subject to prolonged bleeding? Yes No
Is there any personal history of diabetes? Yes No
Is there any family history of diabetes? Yes No
     
     
Have you ever experienced any allergic reactions from Novocaine, Aspirin, Penicillin, or any other medication? Yes No
Have you ever been treated for heart trouble, arthritis, epilepsy, rheumatic fever, kidney or liver involvement? If Yes, which one? Yes No
Have you had any serious illnesses or operations? Yes No
Have you had any injuries or operations on your feet or legs? Yes No
Are you or do you think you are pregnant? Yes No

 

Please take a few moments to fill out this form. Circle anything that may apply to you at this time. By doing so, it will help your doctor treat you in a more complete thorough manner. Thank you!

Gastrointestinal      
Poor appetite Excessive hunger Difficulty chewing Stomach trouble
Difficulty swallowing Excessive thirst Nausea Appendicitis
Vomiting food Abdominal pain Diarrhea Indigestion
Constipation Black stool Bloody diarrhea Ulcers
Hemorrhoids Liver trouble Gallbladder trouble Gas
Weight loss Weight gain Belching Other

 

Genitourinary      
Bladder trouble Excessive urination Scanty urination Kidney stones
Painful urination Discolored urine Frequent urination Difficulty urinating
Prostate trouble Kidney disease Blood in urine Other

 

Nervous      
Numbness Loss of feeling Paralysis Stroke
Dizziness Fainting Headaches Weakness
Muscle jerking Convulsions Forgetfulness Seizure
Confusion Depression Spine disease Brain disease
Other      

 

Eyes      
Eye strain Eye inflammation Vision problem Impaired sight
Eye disease Eye injury    

 

Ears/Nose/Throat      
Ear pain Ear noises Ear discharge Speech difficulty
Hearing loss Nose pain Nose bleeding Dental problems
Nose discharge Breathing difficulty Sore gums Hoarseness
Sore mouth Sore throat Other  

 

Cardiovascular      
Chest pain Pain over heart Leg pain on walking Feet swelling
Heart attach High blood pressure Rapid heart beat Hand swelling
Varicose veins Heart problems Night sweats Weakness
Tiredness Other    

 

Respiratory      
Persistent cough Difficulty breathing Bronchitis Wheezing
Lung problems Coughing up blood Emphysema Hay fever
Coughing up phlegm Asthma Shortness of breath Other

 

Integument      
Itching Psoriasis Bruises Hives
Skin rash Abrasions Ulcerations Eczema
Moles Discolorations Skin cancers Birth marks
Deformed nails Other    

 

Musculoskeletal      
Arthritis Stiffness Club foot Bursitis
Joint disease Muscle pain Sciatica Sprains
Lumbago Fractures Other  

 

Allergies      
Penicillin Morphine Adhesive tape Aspirin
Sulfa drugs Antibiotics Any foods Codeine
Other drugs      

 

Hematological      
Anemia Taking Coumadin Taking Aspirin Jaundice
Bleeding disorder Other    

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