Patient History

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Address(Required)
Marital Status(Required)
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Podiatric History

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Family History: Siblings: Alive(Required)
Mother alive(Required)
Father alive(Required)
Diabetes: Do you test glucose every day?(Required)
Recreational Drug Use
Nature of pain:(Required)
Onset:(Required)
Frequency:(Required)
Timing:(Required)
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SYMPTOMS

Constitutional Systems
Good general health(Required)
Recent weight change(Required)
Fever(Required)
Fatigue(Required)
Eyes
Eye disease(Required)
Wear glasses/contact lenses(Required)
Blurred/Double Vision(Required)
Glaucoma(Required)
Ears/Nose/Mouth/Throat
Hearing loss or ringing(Required)
Earaches or drainage(Required)
Chronic Sinus Problems or Rhinitis(Required)
Nose bleeds(Required)
Mouth sores(Required)
Bleeding gums(Required)
Bad breath or bad taste(Required)
Sore throat or voice changes(Required)
Swollen glands in neck(Required)
Cardiovascular
Heart trouble(Required)
Chest pain or Angina Pectoris(Required)
Palpitation(Required)
Shortness of breath with walking/laying flat(Required)
Swelling of feet, ankles, hands(Required)
Atrial Fibrillation(Required)
Respiratory
Chronic or frequent coughs(Required)
Spitting up blood(Required)
Shortness of breath(Required)
Asthma or wheezing(Required)
Gastrointestinal
Loss of appetite(Required)
Change in bowel movements(Required)
Nausea or vomiting(Required)
Frequent diarrhea(Required)
Painful bowel movements or constipation(Required)
Rectal bleeding/blood in stool(Required)
Abdominal pain or heartburn(Required)
Peptic ulcer (stomach/duodenal)(Required)
Genitourinary
Frequent urination(Required)
Burning or painful urination(Required)
Blood in urine(Required)
Musculoskeletal
Joint pain(Required)
Muscle pain or cramps(Required)
Back pain or back injury(Required)
Difficulty walking(Required)
Joint stiffness/swelling(Required)
Rheumatoid Arthritis(Required)
Weakness of a muscle or joint(Required)
Integumentary (Skin/Breast)
Rash or itching(Required)
Change in skin color(Required)
Change in hair or nails(Required)
Varicose veins(Required)
Neuorological
Frequent or recurring headaches(Required)
Light-headed or dizzy(Required)
Convulsions or seizures(Required)
Numbness/tingling sensation(Required)
Tremors(Required)
Paralysis(Required)
Stroke(Required)
Head injury(Required)
Memory loss or confusion(Required)
Nervousness(Required)
Depression(Required)
Insomnia(Required)
Anxiety(Required)
Panic attacks(Required)
Endocrine
Glandular/hormone problems(Required)
Thyroid disease(Required)
Diabetes Insulin/Non-insulin?(Required)
Excessive thirst/urination(Required)
Skin becoming dryer(Required)
Hematological/Lymphatic
Slow to heal after cuts(Required)
Bleeding/bruising tendency(Required)
Anemia(Required)
Phlebitis(Required)
Past transfusion(Required)
Enlarged glands(Required)
History of skin reaction or other adverse reaction to Penicillin, Sulfa, other antibiotic(Required)
Reaction to Morphine, Demerol, or other narcotics(Required)
Reaction to novacaine or other anesthetics(Required)
Reaction to aspirin or other pain remedies(Required)
Reaction to other drug/medications(Required)
Food allergies?(Required)
Latex allergies?(Required)
NOTICE OF PRIVACY PRACTICE: THIS IS TO ACKNOWLEDGE THAT ANKLE & FOOT SPECIALISTS OF MARION, INC NOTICE OF PRIVACY PRACTICES HAS BEEN MADE AVAILABLE TO ME ON THE DATE STATED BELOW: IN ORDER FOR US TO SUBMIT A CLAIM FOR SERVICES COVERED UNDER YOUR POLICY, WE MUST HAVE YOUR AUTHORIZATION TO RELEASE MEDICAL INFORMATION TO YOUR INSURANCE CARRIER. I AUTHORIZE DR. TIMOTHY J. BROWN / DR. MATTHEW J. BROWN/DR. ANDREW J, BROWN TO FURNISH MY INSURANCE COMPANY WITH ALL NECESSARY INFORMATION REGARDING MY PRESENT ILLNESS OR INJURY. I ALSO AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO DR. TIMOTHY J. BROWN/ DR. MATTHEW J. BROWN/ DR. ANDREW BROWN FOR MEDICAL SUPPLIES OR SERVICES PROVIDED. I GIVE PERMISSION TO DR. BROWN TO EXAMINE AND TREAT MY ANKLE AND/OR FOOT CONDITIONS. IF SURGERY IS TO BE PERFORMED, THIS FORM IS TO BE USED IN CONJUNCTION WITH A SURGERY CONSENT FORM.

PATIENT FINANCIAL POLICY

YOUR UNDERSTANDING OF OUR FINANCIAL POLICIES IS AN ESSENTIAL ELEMENT OF YOUR CARE AND TREATMENT. IF YOU HAVE QUESTIONS, PLEASE DISCUSS THEM WITH OUR FRONT OFFICE STAFF OR MANAGEMENT.

• AS OUR PATIENT, YOU ARE RESPONSIBLE FOR ALL AUTHORIZATIONS/REFERRALS NEEDED TO SEEK TREATMENT IN THIS OFFICE.

• UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE IN ADVANCE BY YOU, OR HEALTH INSURANCE CARRIER, PAYMENT FOR OFFICE SERVICES ARE DUE AT THE TIME OF SERVICE. WE WILL ACCEPT VISA, MASTERCARD, DISCOVER, CASH OR CHECK.

• YOUR INSURANCE POLICY IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY. AS A COURTESY, WE WILL FILE YOUR INSURANCE CLAIM FOR YOU IF YOU ASSIGN THE BENEFITS TO THE DOCTOR. IN OTHER WORDS, YOU AGREE TO HAVE YOUR INSURANCE COMPANY PAY THE DOCTOR DIRECTLY. IF YOUR INSURANCE COMPANY DOES NOT PAY THE PRACTICE WITHIN A REASONABLE PERIOD, WE WILL HAVE TO LOOK TO YOU FOR PAYMENT.

• WE HAVE MADE PRIOR ARRANGEMENTS WITH CERTAIN INSURERS AND OTHER HEALTH PLANS TO ACCEPT AN ASSIGNMENT OF BENEFITS. WE WILL BILL THOSE PLANS WITH WHICH WE HAVE AN AGREEMENT AND WILL ONLY REQUIRE YOU TO PAY THE CO-PAY/CO-INSURANCE/DEDUCTIBLE.

• IF YOU HAVE NSURANCE COVERAGE WITH A PLAN WITH WHICH WE DO NOT HAVE A PRIOR AGREEMENT, WE WILL PREPARE AND SEND THE CLAIM FOR YOU ON AN UNASSIGNED BASIS. THIS MEANS YOUR INSURER WILL SEND THE PAYMENT DIRECTLY TO YOU. THEREFORE, ALL CHARGES FOR YOUR CARE AND TREATMENT ARE DUE AT THE TIME OF SERVICE.

• ALL HEALTH PLANS ARE NOT THE SAME AND DO NOT COVER THE SAME SERVICES. IN THE EVENT YOUR HEALTH PLAN DETERMINES A SERVICE TO BE “NOT COVERED”, OR YOU DO NOT HAVE AN AUTHORIZATION, YOU WILL BE RESPONSIBLE FOR THE COMPLETE CHARGE. WE WILL ATTEMPT TO VERIFY BENEFITS FOR SOME SPECIALIZED SERVICES OR REFERRALS; HOWEVER, YOU REMAIN RESPONSIBLE FOR CHARGES TO ANY SERVICES RENDERED. PATIENTS ARE ENCOURAGED TO CONTACT THEIR PLANS FOR CLARIFICATION OF BENEFITS PRIOR TO SERVICES RENDERED.

• YOU MUST INFORM THE OFFICE OF ALL INSURANCE CHARGES AND AUTHORIZATIONS/REFERRAL REQUIREMENTS. IN THE EVENT THE OFFICE IS NOT INFORMED, YOU WILL BE RESPONSIBLE FOR ANY CHARGES DENIED.

• FOR MOST SERVICES PROVIDED IN THE HOSPITAL, WE WILL BILL YOUR INSURANCE PLAN. ANY BALANCE DUE IS YOUR RESPONSIBILITY.

• THERE ARE CERTAIN ELECTIVE SURGICAL PROCEDURES FOR WHICH WE REQUIRE PRE-PAYMENT. YOU WILL BE INFORMED IN ADVANCE IF YOUR PROCEDURE IS ONE OF THOSE. IN THE EVENT, PAYMENT WILL BE DUE ONE WEEK PRIOR TO THE SURGERY.

• PAST DUE ACCOUNTS ARE SUBJECT TO COLLECTION PROCEEDINGS. ALL COSTS INCURRED INCLUDING , BUT NOT LIMITED TO, COLLECTION FEES, ATTORNEY FEES AND COURT COSTS SHALL BE YOUR RESPONSIBILITY IN ADDITION TO THE BALANCE DUE TO THIS OFFICE.

• THERE IS A SERVICE FEE OF $25.00 FOR ALL RETURNED CHECKS. YOUR INSURANCE COMPANY DOES NOT COVER THIS FEE.

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