Wayne: (973) 692-1111 Clifton: (973) 692-1111
Patient Name:Date of Birth AgeSEX
Home Phone #Alternate Phone #EmailPrimary Language
Do you have a legal Guardian or healthcare power of attorney? Yes No
If Yes NameRealationship Phone#Emergency Contact
RelationshipPhonePrimary Doctor CareWho Referred You to Us?
IS THERE A FAMILY MEMBER OR OTHER PERSON YOU WOULD LIKE FOR US TO SHARE YOUR MEDICAL INFORMATION?
Primary Insurance Company Name:
Insured NameDate of BirthEmployerContact#
Date Of Birth
PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING(INCLUDE PRESCRIPTIONS,OVER-TIME-COUNTER MEDS AND HERBAL SUPPLEMENTS):
PLEASE LIST ALL PRIOR SURGRIES:
Type of Surgery
PLEASE LIST ALL PRIOR HOSPITALIZATIONS(OTHER THAN FOR SURGERY):
Social History: Single Married Partnered Seperated Divorced Widowed
Use of Alcohol: Never No Longer Use History of Alcohol Abuse
Current Use type Rare Occasional Moderate Daily
Use of Tobacco: Never Quit-How long ago SmokePacks/Day ForYears
Use of Recreational Drugs: Never Quit How Long agotype
current use type Rere Occasional Moderate Daily
How much are you on your feeat at work? 10% 25% 50% 75% 100%
Do others Depend upon you on your feet at work? Childerns Age Pets What kind?
Elderly or Disable Family Members Others
Exercise: Never Rare Occasional Weekly Several Times A Week Daily
Type of Exercise:
Do you have a Family history: Diabetes Cancer Heart Disease High Blood Pressure Stroke Coronary Artery Disease Thyroid Disease Rheumatoid Arthritis
Date of Birth
Allergies None Known Medications
Tape Latex Shellfish Iodine Others
What Specific Problem Brings you to our office today?
Where is the Pain/Problem Located?Please select options
Left Foot: Top of Foot Bottom of Foot Inside of Foot Outside of Foot
Right Foot: Bottom of Foot Top of Foot Outside of Foot Inside of Foot
How Long Ago did this problem first start? Days Week Month Year
Did your Pain Or Problem : Begin all of a Sudden Gradually Develope over time
How would you describe your pain? No pain Sharp Dull Aching Burning Radiatiog Itching Stabbing Other
How Would you Rate your pain on a Scale From 0 to 10? 0 1 2 3 4 5 6 7 8 9 10
Since the time your pain or Problem Begin,Has it Stayed the same Become worst Improved
What make your pain or problem Worse? Walking Standing Daily Activities Resting Dress shoes High Heels Flat shoes Any closed Toe Shoes Running
What Makes Your Pain or Proble Feel Better?
What treatment have you had for this problem?
How was this problem Affected Your lifestyle or ability to work?
Was The Problem caused by an injury?
If yes,was it a work-releated injury Yes No
TO THE BEST OF MY KNOWLEDGE, I HAVE ANSWERED THE QUESTIONS ON THIS FORM ACCURATELY.I UNDERSTAND THAT PROVIDING INCORRECT INFORMATION CAN BE DANGEROUS TO MY HEALTH.I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM THE DOCTOR AND OFFICE STAFF OF ANY CHANGES IN MY MEDICAL STATUS.