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ADVANCED PODIATRIC SPECIALISTS, P,C, · o Gait (WaJking) problems 0 In-toeing ChildlOOd loot...

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2f ll 5 POU P ' fO R AOV,\:'IiCtm I 'OU I,\TRI C PC I :'iS l ll tA :'<f CE; Wc J'i i\n tcl palc in mMI [lla n :o.. I C YI' U im,: I nH insun; tl by II plan we. wilh. payment in Cull 11\ ei t\' h ,·b it. I r yo u a rc hy II plml "e I Jitrt ici p., lt ,,·ilh but do not hit "": an It, .... tu.d;tt..: emd. pll yment ht lidl fur c;lch vi:. it is rt quircd l1nt il II C "crify )· (H.! r ";1 1l'..:r:tpC , Knuwul lI )uur Jns umn,,; c bcndit!!' b yu ur I' Ic;l SC (unlltcl inSll nllKe CI'III I '\II I), \\' ;11 1 qU\'stions lII ay It .,,,c rq : il rd ing your cOI 'crn J,lc 1\ 't :l) ICA R E; Wc : 11\ : :t Pi ll'l ic lp; " ing f l"k dl c;lrc p HlI ·u. lcr M\ .... tlcm·c as wei I n :. } (Iur ill :WI'lUIcc Ilf uny I \\ i II b.: hi Ikd for l it 11\ e\,I.'1': tlml I J, I\:S not lIl ean Il ml i, 1I 'CI""\ kc:. l ;"' ·Crl.'\I P: lUc nls:lf e fM p."\Y'"t! thClr annm,1 ded u..:U hk If II I l;Il< II I. t yet Ot."Cn 11 M. You :ue abu lor an) copa)'mcnl$. \\ hl..:h :In' "f I hc all ll'o .... :d aHltlU III (ur lm item or S £COl"D,\ R" INSUR ANCE : Y ..... ur mroicill d aill l wi ll he f' ol""\v;mlcd !11 )"uu r St.. ....... cull hl f) ' (ir uner L 'i pl:lnat ion o t" bcnc!ib lEOn ) I) (rom prlln ;a l) ' L II 'U rJnec cumpa ny , C:O I',\ Yll l ENTS AN I) Ut:DlJCT I OL F.S : 1\ 11 lII enl:: lin d dcuuc ti hk h..: Ilaid :11 the lillie of le c': . This : II ' r. ml!cm...:n l is pa n II ( yuur enn tr..J el w, th yuur in:-Ll r.lIle c cum pall} Fa I lu lc 011 uu r p,l rl 10 collc ":' l "mII Iet IUCIi tol es frum p al can I I\: cllnsidercd (raud. I f yo u hll\ 'C ,I high I, e will rc qlli rl' }UlI in i'I [)OWN PA YM EN T. St; I,F I'A" : 1': 1}' I11 CIII in (lIII IS\lut :ll Ihc lime (, f :>e n 'lcc dll nut hale h":: I\lh ;'Ii 01\' ·COVE R En R V I( :I::S: hc U II t lu lt MlI\II" <J f t he you ( ..x;d vc m il )" nlli h ..: CA; we l\: d Ilf nut r"::Co\m ahk ur h.\' ,\ ·k dica re 0 1' olher Y 1>11 :I fe tor or Ihe' .... R ... ;IU( J\ LSI A Ul ' , I 0 KI 'l.A TtONS: We ,Ir t! I"e l) uircd h' Ib ll uw Ihl.' II I YUli r III l lll a1\c d curc plan II hk h 1n..1 I1 tl:t lc5 ti S Ih,ll II hen )'nll ... u 1 'I1t l<. 0 11 must hll\, c rcfcwJI rmm IIU T primm) ' phY5id:tn p ri ol' In ":L.'1. spr.: ..: mhy earc, I1lerc li lrc. VII :n fi n:t ll ci :'l l1 y Ii}!" thc I yo ur n:fell':lJ i:<; pl"l;."C nh.: d ;1 \ li ll! ": It( Ih is I·isi !. I ( 011 dll 1It11 hal"\! ,I n: I"crT:\ 1 fn' lII ro ur ...:tIn: physic li lll I I! lil li e Ilf ytlll ... ill he Ii nmtdaJh' t ilT ill! r n:d "cd d ul.' I n fu ll upuu culllpktllln 01 tht 10 our ulliec \\ jlh i n 4R huun <If Ih Y l lU will :II...: . hi: che uplton III n.:. ..... he,I II Jc etA 1M SU B1\II SSION: We will !> u"uu t ), nu r cI;J imli li nd Uli. ... uu in I \(.' re ru.ona hl ) cn n til h cl p1; ":1 pili d "UU f nced ... u 10 eert ui n iufutm: ll io ll di recII) , \1 1' yum III el llll ply wilh lh..: ir hI! " w:trc Ihal lh..: ha lm l": ': d:liIU b your II helher \.r 11 1 '1 }Ilur nlSI H'l lnn ' l" ompa ny )" I'lif el .li m Yuur ill> lI fhlle e ix '1'ldit b II ": ulltmcl l"c en and yll ur In .... U fl lncc CCltnp ml) . PATIENT BILLl I'OC : You will he Sl:n l up 10 I hrc..: .... s l or YI' ur limmd ul rc .s po nsi bi lilY Ico· in5 Urn nC c. . dellnelih lc} al kr p: l )"me lll andfuf cx pl ana tiun o( I EOn) 1 ' t>J I"ru lll you r /\ I he Ihmllll Kl luSI m ll ke. yo ur be 1;\n\,l rJ cd In I'k llsc k c thc .,nice kncm II lin)" ynur bill. artltn!!em.:: nb he 11 lllll e on u ca!>c ttl 'We acc..: p' the f\1 I1 <1I\ mg. POI) n le ' Cal-h, (·hee L. II r V1SMMll :.ter l ' lll d: Am ..: r[( an Ui'c (l \"Crll ';lyl'al An ildd lUI mal $ 25 .UO \l' il1 Uc ;wtleu tn (l ur sl :lI emC nI if thc fc l umcd lor msu Oi ";t! nl fu nd s. In 1.'1 ..:n l Ih al insu r:u Kc !> huu ld h:l pp cn 10 pa) l11 ..:nl hi )" 1 '11. Ih..: pllt i\'u t. wc c. \j)<. -..:I thou II lIul t! fi )rll' l n.l il tnu ur Il llic ..: I II b .... ap pl icil \(I )OUT I ahl ll e polk) my jimJl/ cm! ,..·.I·tUI/ts/h,Ii/, 1- Iv ,\u n l1l..: cd P,ldi: tL rk I' C till nlclli .:: otl :. ..:r. ' ices pro vllbJ. I .. glee In I' "Y Ad dll..: ..: d I'od i:!lrli.' iSI S. PC lilly uup, dd h)' my in (; <l rricl' fur t' \Ir helot\' P RIV 1\ C " ST ,\ lNT : All ) ill f.mll :l t lun UI M: in yt'"I' r ec ord, 1\ it I 11 lilk ll t ill\ lind \I' ll I nol ht !o r 11 )' 01 esc ert \n itt il l}; llu ali l) ClIte 1I 11d I TI : Klm enl liJ' II d I as tu h 1\\i t your cl ll i 11\ 10 you r lUll ! IIU nc ," \k tl . P'\ T I t:f\'T "C:KI'OOW U :OGE OF ,,"O TI CE OF PR I VAC ' 1 ' ltJ\ CT U 'l:S: It )" my n:tlllt t-.: \ow. I :Icl nm\ kd!!c Ih ilt I \111' tl n \:I "CI! II CU P) 01" th..: I\I ,t ico! o(I 'r l\' ''I:), I' rnC IL C<.:li. II ndlh:11 t 1t: II'C (,I r hn d the tt l TCiid if I ::11 dIlISl,.· J .. " ,I uudc nolu nd lhe NU lk e ;1111.1 3 g.rec III Assignmt'1I1 M if "ndil5 I. t he Ul\deI'MJ!lI..: tI . ify Il mt \ (\lr my dcl .... IIJcllt ) h:l\ e \\" 11 h insur.Ull'"C )\n:SI.·Ul .... tl lm d IIS)il! lI di rC1! ll y 10 J\dvlI nc.-d ,'od iKt ric i us . PC all hcnc!it:o.. fIiIY;l h Ie III IIIC rul'" I'I."1u 1l: r..:d. 1 thai I am fi.\r n ''':1 11 It r UI."1. llK l iblcl<. cn·p.."\) an ... l!o r se n il:1.-'S. I he n. ·b) lI ulhuri"...: tllc d(II.·\tll I II rdea ....... ill I in (unna l;'!11 to .. men! l'If llcndir s. I uu thori' ,c RELEA SE OF MEDIt' J\ I. I Nt '\ )1( ;\01 J\ T il l N ' " 111 ) lnsu r: ul\ '"C ,·mrier. l 'r til prm'lI lc \"\llIIiIllUI) li t car .: , I :'lulhort"e Ihe of :'II!Il, t! Uf\: un ;I ll 1 und uslnn d Ihal I II in (unn Ihe , 1I.)l. 10r ·5 L rl hcrc iI Chll ll }!C In I lCllllh msu r:mct- ;nror nm llOIl au d I wus u lrered ;] cupy ,lr Ihe Notice or !' ril il C)' , lI\ d u nt kl 'lol. md il uLi il n'"Cv l il' I (,I III S: Si j! naltl r..: : -- F\ NuNC!" 1 .I .r It PiP< l NS Ill! ,I \ \' A I lT Y: -- Sigul lIU le. ___ _ - - --
Transcript
Page 1: ADVANCED PODIATRIC SPECIALISTS, P,C, · o Gait (WaJking) problems 0 In-toeing ChildlOOd loot problems 0 Rash Did you previously or do you now wear: o o Toe walking NONE of these Shoe

2fll 5 "'1 ~AISCIAL POU P ' fO R AOV,\:'IiCtm I'OU I,\TRIC S PEC!.~ I.I STS. PC

I :'iS l lltA :'<fCE; Wc J'i i\n tclpalc in mMI in~lIr.Lncc [llan:o.. I C YI'U im,: I nH insun;tl by II plan we. I":trlicip;\(~ wilh. payment in Cull i~ ~'xp\';letl 11\ eit\'h ,·b it. I r you arc ;n~"rctl hy II plml "e IJitrt icip., lt ,,· ilh but do not hit"": an It, .... tu.d;tt..: il1~lI ru nCe emd. pllyment ht lidl fur c;lch vi:.it is rtquircd l1nt il II C ~';m "crify )·(H.!r ";11l'..:r:tpC, Knuwul lI ) uur Jnsumn,,;c bcndit!!' b yuur r~~,lOlIsihility, I' Ic;lSC (unlltcl ~llUr inSllnllKe CI'IIII'\II I), \\' ;11 1 un ~ qU\'stions ~vu lIIay It .,,,c rq:il rd ing your cOI'crnJ,lc

1\ 't:l) ICA R E; Wc :11\: :t Pill'l iclp;" ing fl"k dlc;lrc pHlI·u.lcr M\ .... tlcm·c as wei I n:. } (Iur ~ecuudar) ill:WI'lUIcc I l f uny I \\ i II b.: hi Ikd for ~·I'". l it 11\ e\,I.'1': tlml IJ, I\:S not lIlean Ilml i, 1I 'CI""\ kc:. al~ l;"'·Crl.'\I P:lUcnls:lfe r~poIIsi hlc fM p."\Y'"t! thClr annm,1 ded u..:Uhk If II Il;Il< III.t yet Ot."Cn 11M. You :ue abu re~ponsillk lor an) copa)'mcnl$. \\ hl..:h :In' u~hl ily 21~t "f Ihc all ll'o .... :d aHltlUIII (ur lm item or ~I \ i~('

S £COl"D,\ R" INSURANCE: Y ..... ur mroicil l d aill l wi ll he f'ol""\v;mlcd !11 )"uur St.. ....... cullhlf)' m~u r:II I~'C (ir iln~) uner paym~'"11I 11lld/Ol L'ipl:lnation ot" bcnc!ib lEOn ) I) r~"Cchl-d (rom ~:ou r prlln;al)' LII 'UrJnec cumpany,

C:OI',\ Yll l ENTS AN I) Ut:DlJCTI OLF.S: 1\11 en.J'I;t~ lIIenl:: lind dcuuctihk lllu~t h..: Ilaid :11 the lillie of ~f\ lec':. This :II'r.ml!cm...:nl is pan II ( yuur enntr..Jel w,th yuur in:-Ll r.lIlec cum pall} Fa Ilulc 011 uur p,l rl 10 collc":'l Ctrp:t~ ]llcnl~ "mIIIetIUCI itoles frum pal iC ll t~ can II\: cllnsidercd (raud. I f you hll\'C ,I high

"kthl~·libk. I, e will rcqlli rl' } UlI i n jI;'l~ i'I [)OWN PA YMENT .

St; I,F I'A" : 1':1}' I11CIII in (lIII IS\lut :ll Ihc lime (, f :>en 'lcc i r ~n Ll dll nut hale h"::I\lh ill ~ II!':l llce.

;'Ii 01\' ·COV E R En s ~: R VI( :I::S: l'ka~c hc U II ~ rc tlult MlI\II" <J f the ~I'v i c<.:~ you (..x;d vc m il )" nlli h..: CA; wel\:d Ilf nut cllJl~ id\'fed r"::Co\mahk ur nec(~~nry h.\' ,\ ·k dicare 0 1' olher i n~Ll rl.:r.'l , Y 1>11 :Ife re~Jlt"n~ihk tor r~)' IIlt:nI o r Ihe' .... ~en'kes.

R ~: ... ;IU(J\ LSI A Ul ' , I 0 KI 'l.A T tONS: We ,Irt! I"el)uircd h' Ib lluw Ihl.' ~lIi\'dinc:. II I YUli r IIIlllla1\cd curc plan II hk h 1n..1I1tl:tlc5 tiS Ih,ll II hen )'nll ... j~il u ~pCl.: i:tJist ~lIch :t~ 1'I1tl<. ~ 0 11 must hll\,c ~ I rcfcwJI rmm ~ IIU T primm) ' ~'are phY5id:tn priol' In ":L.'1. i ll~ spr.:..:mhy earc, I1lerc li lrc. ~ VII :n ~ fi n:tllci:'l l1 y n:spnn~i hlt:

Ii}!" thc SCf'\' l ec~ I cc~· i \·c d . Illllcs.~ your n:fell':lJ i:<; pl"l;."Cnh.:d ;1\ I h~' li ll!": It( Ih is I·isi!. I ( ~ 011 dll 1It11 hal"\! ,I n: I"crT:\1 fn' lII rour pnlllil l ~ ...:tIn: physic li lll II! Ih~ lillie Ilf ~ \·I~it. ytlll ... ill he Ii nmtdaJh' r~Jll,"~il-tk t ilT ill! SCI"Vict.:.~ rn:d"cd d ul.' I n fu ll upuu culllpktllln 01 tht \· i~il. 10 our ulliec \\ jlh i n 4R huun <If Ih i~ \·i.~LI Y llU

will :II...:. hi: ~iwn che uplton III n.:. ..... he,III Jc ~\lur ~ppa illll"cm.

etA 1M SUB1\IISS ION : We wil l !>u"uut ),nur cI;J imli lind Uli. ... I ~l) uu in an~ \\ U~ I \(.' reru.onahl) cnn til hclp1; ":1 ~ 'lUr clllim~ pilid "UUf i nsumnc~ ('ull\p:lI1~

m:t~ nced ~ ... u 10 "u Jlp l~ eertuin iufutm:ll ioll di recII) , \ 1 1' yum r..:~pon~ ihi l i LY III elllllply wilh lh..: ir n:q ll~SI I' l e,,~ hI! "w:trc Ihal lh..: halml":': ur~ l)ur d:l iIU b your re'plln~ihi li l~' II helher \.r 111'1 }Ilur nlSIH'l lnn ' l"ompany p:ty~ )"I'lif el .lim Yuur ill>lI fhlle e ix'1'ldi t b II ":ulltmcl b¢l"cen ~'ou and yllur In .... Ufllncc CCltnpml) .

PATIENT BILLl I'OC : You will he Sl:nl up 10 Ihrc..: nolt~ .... s lor YI'ur limmdul rc.sponsibi lilY Ico·in5UrnnCc.. dellnelihlc} alk r p:l)"melll andfuf cxplanatiun o( I-t~n ..:li l ~ I EOn) I~ I I.-~ci 1't>J I"rulll your i n sur:m~e C"om ll:tII ~/enm~mic.~ , /\ !i~ r I he Ihmlll lKl luSI mll ke. your ,,~C011l 11 1II :t~ be 1;\n\,lrJcd In ~o l icel il ll l~ I'kllsc k c thc ",lIm~ . ,nice kncm II >lllI lm~e lin)" Jimculli~ re)(lh' ill~ ynur bill. l 'OI~ITlI."m artltn!!em.::nb ~-..J1L he 11llllle on u ca!>c ttl CllJ'<.'lI ~ SI:t 'We acc..:p' the f\1 I1 <1I\ mg. POI) 1ll~ 111 nle' hod~' Cal-h, (·heeL. IIr V1SMMll:.ter l 'llld: Am..:r[(an E:"Vfe~sI Ui'c(l \"Crll ' ;lyl'al An ilddlUI mal $25.UO \l' il1 Uc ;wtleu tn ~ (lur sl:lIemCnI if thc dl~\'k I ~ fcl umcd lor msuOi";t!n l funds. In Ih~' 1.'1 ..:nl Ihal ~our insur:uKc e<Jlu l,an~ !>huuld h:lppcn 10 ~Ild pa) l11..:nl h i )"1'11. Ih..: pllt i\'ut. wc c.\j)<.-..:I thou ~ uu II lIul t! fi)rll' ln.l il tnuur Il llic..: III b .... applicil \(I )OUT ll:t l:lnc~.

I h~">! r~' mllh~ ahlll e polk) re,!!i\rIlin~ my jimJl/cm! ,..·.I·tUI/ts/h,Ii/,1- Iv ,\un l1l..:cd P,ldi:tL rk "pcci llh l>I~. I'C till nlclli.:: otl :...:r.' ices provllbJ. I .. glee In I' "Y Ad ~ dll..:..:d I 'od i:!lrli.' Sp~ dlll iSIS. PC lilly h~ lallc~ uup,dd h)' my in ~ Ilr.n!l;c (;<l rricl' fur 1II )'~d t' \Ir Ih ~ helot\' Il 1l tll~ d p ..: r~()n ,

P RI V 1\ C" ST ,\ Tt~M lNT: All) ill f.mll :l t lun UI M: to~etl in yt'"I' record, 1\ i t I r~mai 11 ~Iln lilkll t ill\ lind \I' ll I nol ht u .~cd !o r ~ 11)' 01 h~' r rca~1rI escert \n I'ru ~ itt ill}; lluali l) ClIte 1I11d ITI: Klmenl liJ' II d I as tu ~ II h1\\i t your clll i 11\ 10 you r i n ~um l' t..: ":IIIIIP:II\~' lUll! ell!l1 l1~t ~ IIU ;l ~ nc,"\k tl .

P'\ T I t:f\'T "C:KI'OOWU :OGE OF ,,"OTI CE OF PR IVAC' 1' ltJ\CT U ' l :S: It )" louh~etibm~ my n:tlllt t-.:\ow. I :Icl nm\ kd!!c Ihilt I \111' tln\:I"CI! II CUP) 01" th..: I\I ,t ico! o ( I'rl\'''I:), I' rnCILC<.:li. II nd lh:11 t 1t:II'C (,Ir hnd the opportun i l~ ttl TCiid if I ::11 dIlISl,.· J .. " ,I uudcnolund lhe NUlk e ;1111.1 3g.rec III jl '~ t~rm~.

Assignmt'1I1 M if"ndil5 I. the Ul\deI'MJ!lI..:tI. c~r1 ify Ilmt \ (\lr my dcl .... IIJcllt ) h:l\ e e')h'rns~ \\" 11 h m~ insur.Ull'"C a~ )\n:SI.·Ul .... tl lmd IIS)il! lI di rC1!lly 10 J\dvlI nc.-d ,'od iKt ric Sp~ciK I ius. PC all !IIM\I~Il1C.· hcnc!it:o.. fIiIY;l h Ie III IIIC rul'" ~f\' I,"~'" I'I."1u1l:r..:d. 1 IIllder~:tnd thai I am n'~HI.,;hk fi.\r rru~ n ''':111 It r UI."1.llKliblcl<. cn·p.."\) nJoo:nl~ an ... l!or nUIl·~·" '· ..: r~'"Il

sen il:1.-'S. I hen.·b) lIulhuri"...: tllc d(II.·\tll III rdea ....... ill I in (unnal;'!11 ncccs!>'I~' to ~ecur .. 1' 3~ men! l'If llcndirs. I uuthori',c RELEASE OF M EDIt' J\ I . I Nt '\ )1( ;\01 J\ T il l N '" 111) lnsur:ul\'"C ,·mrier. l'r rcquc~lcd phy~iei ,m til prm'lIlc \"\llIIiIllUI) li t car.:, I :'lulhort"e Ihe tI~e of t hl ~ :'II!Il,t! Uf\: un ;Ill in~uf :111ct

~!1h1ll b:~lIln~

1 unduslnnd Ihal it l ~ m~ fl."s)\n"~ I hl l ll~ III in (unn Ihe ,1I.)l.10r·5 \,mC~ Lrlhcrc 1~ iI Chllll}!C In m~ IlCllllh msur:mct- ;nrornmllOIl aud : Ickn"wlcd~e I wus u lrered ;] cupy ,lr Ihe Notice or !'ril ilC)' I'I~Ie l icc~ ,lI\d untk l'lol.md iluLi iln'"Cvl il' ~ I(,I IIIS:

Si j!naltl r..:: --F\ NuNC!" 1.I .r ItPiP< lNS Ill! ,I \ \' A IlTY:

-- SigullIUle. ___ _ - ---

Page 2: ADVANCED PODIATRIC SPECIALISTS, P,C, · o Gait (WaJking) problems 0 In-toeing ChildlOOd loot problems 0 Rash Did you previously or do you now wear: o o Toe walking NONE of these Shoe

ADVANCED PODIATRIC SPECIALISTS, P,C, "a step ahead in podiatric medicine & surgery"

J, ~~_ authorize Advanced Podiatric Specialists to access my prescriptions through Electronic Health Exchange.

Signature: ________ _ Date : _____ _

Page 3: ADVANCED PODIATRIC SPECIALISTS, P,C, · o Gait (WaJking) problems 0 In-toeing ChildlOOd loot problems 0 Rash Did you previously or do you now wear: o o Toe walking NONE of these Shoe

WELCOME

PATIENT INFOI!MATJON:

Na me: ___ ._ ... _ _ _______________ Social Security #: __ • __ • __

Date of Birth: _l_ .J __ Sex : M __ F_. Age: __ Marital Status: S_ M_ ))_ W._ Othc,_

Addrcss:____ __ . ___ __________________ _ • _ _ w' • • • __ '. ' • __ _ _ __ _ _ • ___ _

City: -._. __ . State: Zip Cudc: __ ._._ Coll llty: __ . __ . _ _ . __ _

Rthnicit),: Hispanic _ _ • Non-J fispanic. ___ _ ({ace: --_ ... _ __ I.angullgt' : _ _ ___ ., __ . ____ ___ ..

How Would you LiJu~ U~ to confirm your llrpointmcnt: 1·lome ._ C<II_ Emllil Tcxt_

Home: ( __ )) __ . __ _ C.II : ( __ l..._._·o __ •• •

Email: _______ .. _ ....• __ . __ _ .... _._-----Occupntiun: ____________ • ____ Empluycr: ____________ . .. .

EMERGF.NCY CO NT ACT:

Na m c: _____________________ RcI:lti olls hip to Yuu : -_ . . _--Address: ____ . _____ . __ C ity: - --- -- ---- - _.-Oaytime phone numhel' : (. __ )L __ ' _ __ . . _ 'W •

HOW J)1Il YOU HEAl! AnOUT o u a OFFICE: -.- .. _---_.-._--- . ..

Primary Care Physidan : __________ ._ • "W"

I,OC<ltiol1: ... _------INSURANCE INFORMATION:

Primary Insun\ncc: _____ _ . __ _ . _ _ C(lf1:1 y/l) ('ducla hlt~ : _____ . ____ _

Name of Policy holder: •

_ _______ .. Relationship: ____ .... . . _____ _ ..

Policy Hulder 's date of birth : _, __ ,. __ )Julicy holder'.1; S ()ci<11 St·curi.y #: __ .-. _ -__

Sccoml:try Insu rance: ___ _ --_ .. _._- Cnp:lyll )cd uct:1 h Ic: -_.

Nll mc of }'ulic), holder : ., ___ _ . --_ .. Hclntinnshi(l: _____ . __

I'olic), H older's dat e of birth: _( _, __ Pulicy huhler' s Social Security II: _ _ • . __ -. __

Page 4: ADVANCED PODIATRIC SPECIALISTS, P,C, · o Gait (WaJking) problems 0 In-toeing ChildlOOd loot problems 0 Rash Did you previously or do you now wear: o o Toe walking NONE of these Shoe

00 HOT COPY BlJJIt FOIIM$. ORIGINAL fORMS W1l1I1AYE A RED SERIAL HUYlER PIUImD 0YElI MICROPRlHT

OOCUFORMS'" P00-2010 • Page 1 of 2 To The Previous Noted

• •

~,~~~~~~ITNFORMAT10N Patient Ace! II

~~==~====~====~~~==~~==~==~~ .. ~y.~I~==~I~==~-====~ COMPREHENSIVE PATIENT MEDICAL HISTORY ROS/PFSH

Have you hadlbeen treated for: 0 Warts o Athlete's Foot o ComsiGaliuses 0 FcngaI Naas o Leg Of Fool Ulcers 0 Neuroma

o Ingrown nails o Fool Numbness o Broken foot bone(s) 0 Broken Ankle o AIlkle sprain o HammerlMaJlet toes 0 Bunion:. o Flat feet o Cramps In legslfeet 0 Arch pain o Lower back paln 0 Knee pain

o High 8rph foot o Heel pain

o Gait (WaJking) problems 0 In-toeing o ChildlOOd loot problems 0 Rash Did you previously or do you now wear:

o Toe walking o NONE of these

Shoe nserts? [!] 00 Still using them? I!l [ID Do or did they help? [!] [ID OIDIOIies? [!] I!il Still using them? [!] 00 Do or did !hey help? [!] 1!1 The orthotics were obtained from: a Another Poi1Ialrist 0 An OrthopedISt 0 ' _-"", 0 '_~ 0 -. ____ -='" Are your first steps out of bed painful? [!] lEI .,. then subsides? [!] lID Do you get leg cramps , .. during the Day? [!] iEJ ",at Night? [!} lID Percent of waking hotn spent on your feet? /20% 11 40% IIIi1t% II."., I~ Ust the sports/type of dance your are active in:

Does foot pain limit your desired activities? Do you have any difficulty In walking? Any pain in calves or buttocks when walking? Is the pain relieved by stopping & standing still?

DVes O No DYes O No Dyes O No DYes O No

Do you have or have you ever been treated for.

o Stroke 0 Heart Attack 0 High Blood Pressure o Phlebitis 0 VasctJlar Disease 0 A Heart Condition o ~iabetes 0 Poor Circulation 0 KeloidlThlck Scar o Hepatitis 0 liver Disease 0 Eyt!!!s: GlaoeomalManicular Oeg. o Gout 0 Osteoporosis 0 Alzheimer's o Sciatica 0 Lyme's Disease 0 Rheumatic Fever o Arthritis 0 Headaches 0 HearinglEar Disorder o Epilepsy 0 Nerve Disorder 0 Psychiatric Disorder o AnemIa 0 Kidney Disease 0 Thyroid Problem o Asthma 0 Lung Disease 0 Tuben:ulosis o Cancer 0 Stomach Ulcer 0 NONE of these

Do you have vascular grafts? 'II J"!S, 8'J" 'j h ' • .. 1 Do you have joint implants? 'If yes, A'P'rn ~s"""l

Do you have replacement heart valves? Are you now under active chemotherapy? Have you had any other serious illness? It.I$I beIoll1 Have you had any surgory? (If)1!$,. ...... i oe.ro"" Have you ever been hospitalized or been under medical care over 24 hrs? fit ...... e.q:'z , t lIow)

Dyes O N. D yes O N. OVes D Na D yes O N. D yes O No Dves D Na Dyes O N.

Had Surg91)' for.. on dale of: wI compliCations 01:

List relationship to you of family members who have had: Diabetes Foot Problems _____ _ Arthritis Heart Anack ______ _

Stroke High Blood pn .. ~ss~u~ .. :;;:::=:;::;::: "C: Cancer Birth Defects _

, of childbirths Are you currently pregnant? 0 Yes 0 No g Ate"you slow to heal after cuts? 0 Ves 0 No n1 Any abnonnal bruiSing. bleeding or scarring? 0 Ves 0 No ~

Do you smoke now? 0 No 0 Yes Packs/day _ Years_ Did you ever smoke? 0 No 0 Yes Packs/day _ Year5_ ~ If you quit, when did you do so? 0 Afcohollc beverages? l~ 0I'Ie) None Rarely Moderately OaUy Ouit :a Recreational Drugs? (CaWOfI9I None Rarely Moderately Daily QUit "'( Please mark It you take vitamins or supplements that contain 0 garlic, ~

o Gi"!JkD bHoba, 0 ed1inacea, 0 ginseng or 0 Sr. John , WM ~ Are you ct.trrently taking any medications? Us1 below! Ves ~

r

"yes. what happens? Penicillin .~ ...... ,........................... 0 0 Othe< antibOUcs "'" ""'" .••..•.•. 0 0 MofphIne .............................. _.... 0 0 Cocieile ................. _ ............... _ .. 0 0 _______ _ 0etnertlI ......... " ........................... 0 0 01"" _ nor _I ............ 0 0 Novocaine .................................. 0 0

--Otheraneslhetlcs ""' .. ""1 ....... 0 0 Aspirin ............................... " .... , .. 0 0 Empirin. T_ Pl""' .... ' ....... 0 0 Advil, A1eve, 0( Molnn ICItCII) ••• ..• 0 0 - --Qth" pain remedies "'" """I ... 0 0 ____ _ Sulladrugs· ......... · .. " .. ··.· ..... ·· .... · D 0 Adhl!SNe lape .........•............. ...... 0 0 ______ _ Shrvnp, Iodine, or Merthlolate ... 0 0 My other drugs or medications. 0 0

Anything else that you want to tell the doctor? N. Illnesses/Explanations: ____________ _

Patient

J: -~ ~ » en o " L

Page 5: ADVANCED PODIATRIC SPECIALISTS, P,C, · o Gait (WaJking) problems 0 In-toeing ChildlOOd loot problems 0 Rash Did you previously or do you now wear: o o Toe walking NONE of these Shoe

3 ______ -:-____ -::-__ -:-_ _________ --{ Patient

PATIENT'S CURRENT CHIEF COMPLAINTS CC/HPI CClt (! )

LEFT FOOT RIGHT FOOT

Oescn'be 1 or 2 main =:::c"'=tall below &. marX on below the areas wh!ff YOIJ hay" eadt ~~~I~n~wru.~~~~1~.~2~1'~.=.~n~Wy~~~~~ 1

I­I-

m Z ..., :z:

o Please mar1t the location of your first problem or pain on the dia­above wJth a number 1. Describe your problem below and Its I-::-,:,,~N=o~n~.~o~o ':-"'~ if you know. Please describe associated pain 10 the right ,. lIy PakllDlseomfad is:

-- --'--1 ~

My fllSt problem Is ... 0 On Left fool 0 On Righi fool 0 On Both feet.. 0 ShOOting Pain II causes me difficulty: 0 walking, 0 wearing shoes, andlor it "." D Throbbing Paln

, o Sharp PaIn o BurnIng Pain D IIt.j1)ng °

o Aching Peln o Tendemess o Oull Pain

____ Is problem work related? (!] [ID D llngUng

Dale of I I Dale of report to employer: I I 0 Numbness ~~~------~~--~~-----+ @ Please mark location 01 your second problem or pain on the

a number 2. Oescnbe your problem below and I-::-I you know. Please describe associated pain 10 the right - M, PllnlDiscomll)lf I$:

o

My second problem is ... 0 On Left fool 0 On Aighllool 0 On Both fet!L 0 Shoollng PaIn II causes me difficulty: 0 walking, 0 wearing shoes, and/or it ... 0 Throbbing PaIn

__________ Is problem work related? {!] IE]

I J Date of report to employer: I I

o Shatp PaIn o BurnIng Pain D itching o Aching Pain o Tendemess o Dull Pain o Tingling o Numbness

How long ago did tho problem (paln):"'''-tart?: ~ ::;-_0 days. 0 weeks, 0 months. 0 yeitrs ago

pain from my problem occurs: o while walking arnIIor 0 while not walking o endI,, _________ _

o Severe

How long ago did the problem (pain) start?: =:-_ 0 days. 0 weeks, a months, a yeatS ago The pain from my problem occurs: o while walking and/or 0 while not walking o 'mll" _________ _

PATIENT'S DOCTORS - PLEASE TEll US WHOM TO THANK AND WITH WHOM TO COORDINATE YOUR CARE

o,le laSt see~ RI1tmd IDE I was Itnl Of ume /II ~ lor.

--------- - --------- ---------- - '-'-

FOR DOCTOR'S USE - OBSERVATIONS & C OMMENTS

o Patient \vss 0 assisted In completion of this record by or was 0 unable to !;Omplele withoullhe help of: _---::-_ _________ ~ o Translation was done by In 0 Spanish. 0 ___ ___ _ __ 0

o Additional InfOfmaliOnt obtained from 0 Family/Care givers and/or 0 Physician(S) ________________ _

o lab Reportst and/or 0 PJevlous Medical Recordst were rBYlewed. D X·rays1 brought by patlenl from ________ w, ere reviewed. 1E~oo~ ______________________________________________________________________ _

1 have reviewed Ihe lnlormatloo provided above __________ _ __ .. 0 My annotations 10 patient's entries are marked In:=== Doctor's m ! tHl! COLtII' ) Signature X __ Dale I I ... D See Additional Documentation

.. , .. , ~ , , • ! ,,... "'"

Confidential Office Medical Record OOCUFORMS" POO·2010 • Page 2 of 2

c , . "

PreVious Noted

o

Page 6: ADVANCED PODIATRIC SPECIALISTS, P,C, · o Gait (WaJking) problems 0 In-toeing ChildlOOd loot problems 0 Rash Did you previously or do you now wear: o o Toe walking NONE of these Shoe

Ad vanced Podiatric Specialists Patient Medication list

Please carry this with you at all times and update it as often as possible

Patient Name :' __________________ _

DUd d ate ate • •

Medication Dosage (mg) Times per day

Please list any allergies to medications below

WHY DO I HAVE TO FilL OUT ONE OF THESE MEDICATION LISTS AGAIN? ! Research has proven that the most common causes of illness in the elderly and of failed cures in people of any age, are incorrect medication combinations. II is very easy to lake the wrong pills or the wrong dosage.

At most medical appointments, some changes are made in medications. If the doctor doesn 't know precisely what you are on at the beginning of the appointment then there may well be a mistake made by the end of the appointment.

Another common mistake occurs when a patient has one bottle of pills with a generic name and Ihey end up taking a double dose causing severe overdoses and possible severe medical problems. This problem occurs frequently in patients on diuretics, heart medications, antibiotics or arthritis pills.

In addition, mistakes can be made in the doctor's memory, the patient's memory, the typist transfer of thoughts to paper or at the pharmacy. For all of these reasons current and constantly updated medications lists are one of the best ways to assure that medication errors will not be made.


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