ࡱ> QSP bjbj Ijj lbbbbbbb4666,Jl!tnnnn6!!!!!!!$# 1%t*!-b"*!3bbnn!W!333bnbn!3!33Xtbb n -6 m!0!,%k% 3bbbb FAMILY FOOT CENTER Cookeville, Crossville, Livingston, Smithville 2021 Updated Information Although podiatry personnel primarily treat the area in and around your foot, your foot is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the podiatric care you will receive. Thank you for answering the following questions. Patient Information: Patient Name: Dr./Mr./Mrs./Ms. __________________________________________________________________ Last First Middle SSN: ______-_____-______Race:_________Marital Status:___________ Date of Birth: ____/____/______Age: ___________ Address: _____________________________ ___________________ ________ _____________ City State Zip Home No. (___)____ ____________ Cell phone No. (___)___________________ Work Number (___)_________________ Family Physician: Dr.________________________ Location______________Date of Last Visit:______________ Are you a diabetic?  FORMCHECKBOX  Yes  FORMCHECKBOX  No How long a diabetic? ____________Do you use insulin? _______________ Pharmacy Name and City: _________________________ Your Emergency Contact & Number:_______ ______________ Insurance Information Primary Insurance: _______________________ Secondary: ______________________ Insurance Subscriber Information(if different than patient) Name: __________________________ SS#: ______________ DOB: _______ Relationship: ________ (First) (M) (Last)Are you under a physicians care now?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes: ___________________ Have you ever been hospitalized or had a major operation?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes: ___________________ Have you ever experienced 2 falls OR any falls with injury in the last year  FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes: ___________________ Is your influenza vaccination up to date?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes: ___________________ Is your pneumonia vaccination up to date?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes: ___________________ Do You use tobacco?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Medications/Dosage/Frequency:( Prescription and Non-Prescription) ______________________ __________________________ _______________________ ______________________ __________________________ _______________________ ______________________ __________________________ _______________________ What is your current problem? _________________________________________________________________ How long have you had this problem? _________________Any treatment? _______________________ Are you currently taking a blood thinner?____ _________________ __If so what amount?______________ ALLERGIES? PenicillinYes No AnestheticsYes No IbuprofenYes No Other______SulfaYes No TapesYes No CodeineYes No AspirinYes No CortisoneYes No LidocaneYes No ASSIGNMENT OF BENEFITS: I authorize payment of medical benefits to the named provider(s) of professional services rendered. I authorize release of any medical information necessary to process this claim. I verify that the above information and medical history is correct to the best of my knowledge. I give my permission to the named provider(s)at Family Foot Center to perform and administer any necessary procedures. X: PATIENT/GUARDIAN SIGNATURE DATE ________________________ Staff Initial Date Current Height: _______ Current Weight: _______ B/P: _______ Temp. _____Shoes Size: ____ 2021 REVIEW OF SYSTEMS/ CURRENT PROBLEMS: Constitutional (Please circle all that apply): Chills Easily Tired/Fatigue Fever Night Sweats Cardiovascular (Please circle all that apply): Chest Pain Discoloration of toes/foot Leg Cramps Pain or fatigue in feet/legs with exercise/activity Swelling in feet/legs (Edema) Varicose Veins Respiratory (Please circle all that apply): Shortness of Breath/Difficulty breathing Emphysema Gastrointestinal (Please circle all that apply): Abdominal Pain Diarrhea Nausea Vomiting Musculosketal (Please circle all that apply): Ankle Instability (easy twisting injuries) Flat Feet Joint Pain Leg Pain (shin splints) Pain in feet getting out of bed Swelling in joint Swelling leg Toe-in or Toe-out gait (walking) Muscle Aches Integumentary (Please circle all that apply): Atypical moles Rashes Sores on foot or leg Wart(s) Neurological (Please circle all that apply): Burning in Feet Easy to Fall Numb Feet Tingling in Feet Weakness in Feet Endocrine (Please circle all that apply): Excessive Sweating Heat/Cold intolerance Increased skin pigmentation Increased Thirst (Polydipsia) Allergic/Immunologic (Please circle all that apply): Difficulty Healing Seasonal Allergies  None of the Above Patient Name: __________________________ Date: _________________________, 2021     CDI^%-i$/     ' ( ) . / = > ? ^ k  ͻͻͻͻyjtCJUaJjCJUaJjCJUaJCJaJ5CJ\aJ5CJ\aJ5>*5 5CJaJ5CJOJQJCJOJQJ\aJCJOJQJ\ 5CJ\ 5CJ\CJ 6>*] 6>*CJ ]6]56CJ\]CJ$,D]^$%$  $If] 0]^0`` 0^0`^ ^`   ^   5 6 1 2 @ A B G H V W X e f y  o p ~ ѶѲѨўѲєъѲj CJUjCJUj8CJUjCJU5\jPCJUjCJU jCJUCJ\ CJ\aJ 5CJaJCJaJ 5CJ\5CJOJQJCJOJQJ\aJ3 ^  5 6 z  _7du  !$If$If_$$Ifli`'064 lal !d$If` $If` ~  $%&+,:;<IJ_z{/s멥5CJ\aJ 6CJaJCJaJ66aJ>*CJ\5CJ 5>*CJjCJUjdCJUjCJUj|CJU 5CJ\5\jCJUCJ jCJUjCJU47/}smmg$If] ^` ^`_$$Ifl.`'064 lal $If]  !$If fZ[^(1@INV[alqrs70c 7Kx{~ 5CJ\j5UmHnHu5CJ5CJ5\5>*CJ56CJ\] 6CJ] 5CJ\ 6CJ] 5CJ\ 5CJ\CJCJB*CJhphB*CJ\hphCJ\CJaJ6&<Pf~ $$Ifa$~.( $$Ifa$$If$$If4֞ *bNr$80$4 a9$$Ifֈ *bN80$4 a $$Ifa$&<Nd $$Ifa$$IfdfZ[^B8**&d P ]  `']$$If2ֈ *bN80$4 a^rstuvwxyz78C^ & F ]^C^j12cds|} & F & F^8JW|  78IVar8^8` & F^Kx|}~ $^a$$ !^`a$ !^` !^ & F    jUCJ\ 5CJ\ 5>*CJ\      / 0PP&P/ =!"#$ %3 0PP&P/ =!"#$% P/ 0PP&P/ =!"#$%3 0PP&P/ =!"#$% P/ 0PP&P/ =!"#$%/ 0PP&P/ =!"#$%3 0PP&P/ =!"#$% P/ 0PP&P/ =!"#$%3 0PP&P/ =!"#$% P/ 0PP&P/ =!"#$%3 0PP&P/ =!"#$% P3 0PP&P/ =!"#$% P/ 0PP&P/ =!"#$%3 0PP&P/ =!"#$% P/ 0PP&P/ =!"#$%/ 0PP&P/ =!"#$%3 0PP&P/ =!"#$% P/ 0PP&P/ =!"#$%(1h/ =!"#$%tDeCheck1hDetDeCheck1tDeCheck2tDeCheck1tDeCheck2tDeCheck1tDeCheck2tDeCheck1tDeCheck2tDeCheck1tDeCheck2tDeCheck1tDeCheck2 i8@8 NormalCJ_HaJmH sH tH F@F  Heading 1$@&^` 5CJ\F@F  Heading 2$0@&^`0 5>*\6@6  Heading 3$@& 5CJ\4@4  Heading 4$@&6aJ>@>  Heading 5$0@&^0 5CJ\4@4  Heading 6$@&5aJ>@>  Heading 7$0@&^0 5CJ\N@N  Heading 8$$@&`a$56>*OJQJ]<A@< Default Paragraph Font*>@* Title$a$5\6P@6  Body Text 2$a$5\*B@*  Body TextCJ4 @"4 Footer  !CJaJBnB  F1FfFFFF.GcGGGG/HdHHHH,IaIID]^$%$^56z _ 7 /    ( 2 = I J P [ a l t  deh|}~ABMht;<mn} !"BTaABS`k| U   !00000000H00000000000000000000000000000008000X0X00000000000000000000000000h000(0(0000000000000000000000000000000000000000000000@00000000000000000000000000000@0000000  ~ ! 7~d^C "(.>1AGWo   % + ; z G$G$G$G$G$G$G$G$G$G$G$G$G$G$8@v(  >   "?B S  ? \ MtCheck1Check2 OLE_LINK6!! !DR9Es [_ !33333333333CDDFI\ (/78?CF]dmzR^dg466 d  . / dghh~ !FFC-USERE\\ffc-nas\Shared_Docs\Updated Forms KM 2021\Update Form 2021 kjrc.docZ^h^`OJPJQJ^Jo(h   ^ `OJQJo(o   ^ `OJQJo( xx^x`OJQJo( HH^H`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o ^`OJQJo(Z^Z^8-) @00[B        56    ( 2 = I J P [ a l t  !@DDdDD(  P@PP(@UnknownG:Ax Times New Roman5Symbol3& :Cx ArialA& Arial Narrow?5 :Cx Courier New;Wingdings"1haGaG 12 &K (!0X]3QHPFAMILY FOOT CENTER KaseyCarterFFC-USEROh+'0|  , 8 D P\dltFAMILY FOOT CENTERAMI KaseyCarteraseNormalr FFC-USERer4C-Microsoft Word 9.0@@@^@Xq12՜.+,0 hp|  Y& X FAMILY FOOT CENTER Title  !"#$&'()*+,./0123456789:;<=>?ABCDEFGIJKLMNORRoot Entry Fpq/TData %1Table-%WordDocumentISummaryInformation(@DocumentSummaryInformation8HCompObjjObjectPoolpq/pq/  FMicrosoft Word Document MSWordDocWord.Document.89q