Patient Information Form | Strash Foot & Ankle Care

Patient Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Date of Birth *

Male
Female

Social Security Number

Marital Status

Single
Married
Divorced

Patient's Occupation

Patient's Employer

Employer's Address

Address Line 1

Address Line 2

City

State

Zip Code

Employer's Phone Number

Emergency Contact Name

Emergency Contact Phone Number

How did you hear about our office?

If you chose Doctor's office or Urgent Care Clinic list the name below.

Office or Clinic Name

Medical History

What foot or ankle concern would you like addressed by your doctor today?

Location of your problem

When did your condition start?

Was it caused by an injury?

Yes
No

If yes, how did it happen?

Indicate your day to day pain level (1=Minimal, 10=Intolerable)

What makes it worse?

What modifications have you tried?

Allergies

If other, please describe

Medications

Medication Name

Dose

Medication Name 2

Dose 2

Medication Name 3

Dose 3

Medication Name 4

Dose 4

Medication Name 5

Dose 5

Medication Name 6

Dose 6

Recent Surgeries

Shoe Size

Height

Weight

Do you smoke?

Yes
No

If yes, how many packs per day?

Do you drink?

Yes
No

If yes, how often?

Family Medical History (Not You)

Click all that apply

Your Medical History

Click all that apply

Have you had any of these symptoms in the last 6 months?

Your Pharmacy

HEB
Walgreens
CVS
Wal-Mart

Other Pharmacy

Pharmacy Location

Approximate location (street or corner)

Family Doctor

Your Email

Signature *

Typing your name in this box authorizes the release of any medical information necessary to process this claim and request payment of benefits, government or other to be made to: Alamo Family Foot Care, PA. (AFFC) I hereby give permission to Alamo Family Foot Care, PA to examine, administer treatment and perform such procedures as may be deemed necessary in the diagnosis and treatment of my condition. I hereby acknowledge the receipt of the privacy practices (Health Information and Portability Act) of AFFC.