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Patient Information Sheet
 
Social Sec: *
Date: * mm/dd/yyyy
Phone Number : *
Cell Phone : *
Last Name : *
First Name : *
Middle Name : *
Age : *
Birth Date: mm/dd/yyyy
Sex Male Female
  Single Widow Married Divorced
Address : * City:
  State:
  Zip Code:
What is your primary language spoken? : *
Occupation : *  
Business Phone : *  
Employer : *  
Employer Address : * Emp City:
  Emp State:
  Emp Zip Code:
How did you hurt your foot: Work Auto accident Other
Do you have advanced directives :including living wills or durable powers of attorney for healthcare:
E-mail Address:
Name of family Doctor:
Whom may we thank for referring you to our office:
I give permission to South Florida Foot and Ankle Center to release any information requested by my insurance company and give South Florida and Ankle Center permission to perform general procedures in the diagnosis and/or treatment of my foot condition. I authorize payment of medical benefits to South Florida Foot and Ankle Center for services provided. .

* = Input is required
Patient/Guardian Signature Date mm/dd/yyyy
Please ask our staff to help you with this form if you would like assistance
 
What is your foot or ankle concern?
How have you treated this problem at home?
Have you injured your feet before? If so how?
What type of work do you do?
Your Height :
Weight :
Shoe size/width :
Have you had foot treatment before?
By whom?
Did anything disappoint you about your last visit to a foot specialist?
Have you had prior surgery on your foot and/or ankle?
What medications are you now taking?
Are you Pregnant? Yes No
Do you Smoke?
Amount per day?
Do you drink alcohol?
Amount per week?
To my knowledge, I am not allergic to any medications I am allergic to (please circle):
Diabetes Asthma Anemia Bleeding tendencies Cancer Phlebitis Leg cramps Glaucoma Gout Heart trouble Kidney trouble Stroke ¬High blood pressure Nervousness Rheumatism/Arthritis Stomach ulcers Heart murmur Hepatitis Other
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Fun Facts
Work and Sports Injuries
Foot and Ankle Injuries
New Total Ankle Replacement Procedure
Royal Palm Beach, West Palm Beach, Lake Worth, Belle Glade
Shoe Drive for Haiti
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