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New Patient Registration Form: Minor

Demographics

Demographics

Patient First Name

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Patient Last Name

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Cell Phone Number:

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Secondary Phone Number:

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Street Address:

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City:

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State:

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ZIP:

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Age:

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Date of Birth:

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Gender:

Male

Female

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Social Security Number:

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Email

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Preferred method of contact?

Cell phone

Secondary phone

Email

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Current Employer:

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Work Phone:

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Employer Address:

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Primary Doctor:

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Phone Number:

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City:

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Emergency Contact Information

Emergency Contact Information

IN CASE OF EMERGENCY, who will be notified?

Contact name:

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Phone:

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Relationship:

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How did you hear about Northern Illinois Foot & Ankle Specialists?

Billboard

Office Sign

Internet/Website

Insurance Company

Event/Other

Doctor Referral

Prior Patient Referral

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Insurance & Pharmacy Information

Insurance & Pharmacy Information

PLEASE CONTACT YOUR INSURANCE COMPANY PRIOR TO YOUR APPOINTMENT TO VERIFY YOUR BENEFITS

Will you be using insurance?

Yes

No

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Insurance:

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Policy Holder's Name

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Relationship to Policy Holder

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Policy Number

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Group Number

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Preferred Pharmacy:

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City

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State

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Patient History

Patient History

Height:

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Weight

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Shoe Size

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Preferred Language

English

Spanish

Other

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Ethnicity - Hispanic or Latino?

Yes

No

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Race

Caucasian

Hispanic

African American

Asian

Native American

Pacific Islander

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Reason for today's visit:

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Location of area's involved

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How long have you had this condition:

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What aggravates your condition:

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What makes your condition improve

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Pain level (on a scale of 0-10, 10 being extreme)

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Type of pain

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Occupation:

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Percentage of day you spend on your feet

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Smoking/Drinking History

Do you smoke?

Never Smoked

Current Smoker

Former Smoker

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Do you drink alcohol?

Yes

No

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List all current medications & dosages, including non-prescription, over-the-counter medications.

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ALLERGIES: MEDICATION/ENVIRONMENTAL

Penicillin

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Sulfa

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Tetracycline

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Codeine

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Adhesive Tape

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Latex

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Iodine/Betadine/Shellfish

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Radiographic Dye

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Non-steroidal Anti-Inflammatories (Advil, Motrin, Aleve)

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Activity Level

No limitations of daily activities

Limitation of recreational activity

Max walking distance: greater than 8 blocks

Max walking distance: 4-7 blocks

Max walking distance: 1-3 blocks

Max walking distance - Less than 1 block

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Past Medical History

Past Medical History

Anemia

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Arthritis (Osteoarthritis)

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Arthritis (Rheumatoid)

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Asthma

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Cancer

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COPD

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Blood disorder

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Back pain

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Blood clots

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Kidney Disease

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Gout

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Hepatitis (B or C)

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HIV+/AIDS

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High Blood Pressure

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Thyroid Problems

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Heart Disease

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Reflux

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Seizures

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Stroke

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Neurological disorders

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Stomach Ulcers

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Diabetes

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Other

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If female, is there a chance you are pregnant?

Yes

No

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Past Surgical History

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Family History of Medical Problems

Family History of Medical Problems

Alcoholism

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Heart Disease

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Seizures

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Asthma

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Hepatitis

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Stroke

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Blood Disorder

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High Blood Pressure

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Thyroid Problems

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Cancer

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Kidney Disease

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Foot Issues

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Diabetes

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Neurological Disease

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Other

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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FOOT & ANKLE
CONDITIONS

Northern Illinois Foot & Ankle Specialists

750 E Terra Cotta Ave

Unit C

Crystal Lake, IL 60014

(847) 639-5800

Fax: (815) 526-3467

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