Patient Information

New patients fill out all areas of this form. Once you complete one section click on the next section and fill out.

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Date
SS/HIC/Patient ID #
Last Name
First Name
Address
City
State		Outside US Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
Zip
E-mail
Sex		Female    Male
Age
Birthdate
Relationship Status		Married Widowed Single Minor Separated Divorced Partnered
Patient Employer/School
Employer/School Address
Employer/School Phone
Spouse's Name
Spouse's Employer
Whom do we thank for referring you?

Phone Numbers

Home Phome
Cell Phone
Best time and place to reach you
IN CASE OF EMERGENCY CONTACT:
Name
Relationship
Home Phone
Work Phone

Insurance

Who is responsible for this account
Relationship to Patient
Insurance Co.
Group #
Is Patient covered by additional Insurance		Yes  No
Subcriber's Name
Birthdate
SS #
Relationship to Patient
Insurance Co.
Group #
Assign insurance benefits to		Dr Moshe Hillel

INSURANCE ASSIGNMENT AND RELEASE

I certify that I have insurance coverage with above-named Insurance Company(ies) and assign directly to above-named doctor 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 authorize the use of my signature on all insurance submissions.

The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date of submitting this form.

MEDICARE/MEDIGAP AUTHORIZATION

I request that payment of authorized Medicare benefits and, if applicable, Medigap benefits, be made either to me or on my behalf to above-named doctor for any services furnished to me by that provider.

To the extent permitted by law, I authorize any holder of metical or other information about me to release to the Centers of Medicare and Medicaid Services, my Medigap insurer, and their agents any information needed to determine these benefits or benefits for relted services.

Signature of Beneficiary, Guardian or Personal Representative:

Please print name of Beneficiary, Guardian or Personal Representative:

Date:     Relationship to Beneficiary:

Podiatric History

What is the chief complaint for which you came to be treated? (Include foot, ankle, knee, thigh, and hip complaints.)
Have you ever been to a Podiatrics before?		Yes  No
If yes, please list: Name
Last visit
Is there any personal or family history of diabetes?		Yes  No
Your occupation
Cigarette/Tobacco use
Years smoked
Athletic activities in which you participate (please list and indicate frequency)

Please indicate which foot problems you have or have had in the past:
Ankle Pain		Yes  No
Athlete's Foot		Yes  No
Bunions		Yes  No
Corns and Calluses		Yes  No
Cramps or Numbness in Feet or Legs		Yes  No
Flat Feet		Yes  No
Foot or Leg Cramps		Yes  No
Heel Pain		Yes  No
Ingrown Toenails		Yes  No
Plantar Warts		Yes  No
Swelling in Ankles or Feet		Yes  No
Tired Feet		Yes  No

Medical History

Choose "Yes" or "No" to indicate if you have had any of the following:

AIDS/HIV		Yes   No	Hemophilia		Yes   No
Allergies to Anesthetic		Yes   No	Hepatitis or Jaundice		Yes   No
Allergies to Medicine or Drugs		Yes   No	High Blood Pressure		Yes   No
Anemia		Yes   No	Kidney Problems		Yes   No
Angina		Yes   No	Liver Disease		Yes   No
Arthritis		Yes   No	Low Blood Pressure		Yes   No
Artificial Heart Valves or Joints		Yes   No	Neuropathy		Yes   No
Asthma		Yes   No	Psychiatric Care		Yes   No
Back Problems		Yes   No	Radiation Treatment		Yes   No
Bleeding Disorders		Yes   No	Rash		Yes   No
Cancer		Yes   No	Respiratory Disease		Yes   No
Chemical Dependency		Yes   No	Rheumatic Fever		Yes   No
Chest Pain		Yes   No	Shortness of Breath		Yes   No
Chroinc Diarrhea		Yes   No	Sinus Problems		Yes   No
Circulatory Problems		Yes   No	Special Diet		Yes   No
Diabetes		Yes   No	Stroke		Yes   No
Ear Problems		Yes   No	Swelling in Ankles, Feet		Yes   No
Epilepsy		Yes   No	Swollen Neck Glands		Yes   No
Eye Problems		Yes   No	Tired Feet		Yes   No
Fainting		Yes   No	Tuberculosis		Yes   No
Foot or Leg Cramps		Yes   No	Ulcers		Yes   No
Gout		Yes   No	Varicose Veins		Yes   No
Headaches		Yes   No	Venereal Disease		Yes   No
Heart Disease		Yes   No	Weight Loss, unexplained		Yes   No

Surgeries you have had
Hospitalization other than for the surgeries listed
Family physician
Last visit date

Are you now, or have you been, under any other doctor's care for any reason over the past two years?

Yes No

If yes, please explain

 

Medications

Include prescriptions, over-the-counter medications and vitamins
Pharmacy name(s)
Pharmacy phone(s)
Do you take oral contraceptives		Yes No

Allergies

Adhesive/Tape			Local Anestethetics
Anticoagulant Therapy			Novocaine
Aspirin			Penicilin
Codeine			Seafoods
Demerol			Sulfa
Iodine
Other

Treatment Consent

I hereby consent and give my permission to the doctor (and the doctor's assistants or designated replacement) to administer and perform such procedures upon me as the doctor deems necessary.

Signature of Patient, Parent, Guardian or Personal Representative
Date
Please print name of Patient, Parent, Guardian or Personal Representative
Relationship to Patient