Patient History And Physical Form

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Advanced Ankle & Foot Center, LLC
Patient History and Physical Form
Office use only: Chart ID _______________________
NAME: _____________________ ____________________ _________
SEX: MALE FEMALE
Last
First
M.I
BIRTHDATE _____/_____/______
SOCIAL SECURITY NUMBER: _________-________-_________
ADDRESS: __________________________________________________
______________
Street
Apt #
____________________________
_______________
________________
City
State
Zip Code
HOME PHONE: (
) _______-________WORK: (
) ________-________CELL: (
)________-_________
RACE:  American Indian  Asian  Black or African American  Native Hawaiian  White  Other
 Hispanic or Latino
 Non-Hispanic or Latino
 Decline
:
ETHNICITY
MARITAL STATUS: ________________
EMAIL: ____________________________________________
HOW DID YOU HEAR ABOUT OUR OFFICE? _________________________________________________________________
REFERRING PROVIDER: ________________________________ CITY: ___________________
PHONE:_____________
PRIMARY CARE PROVIDER: ____________________________ CITY: ___________________
PHONE:_____________
EMPLOYMENT STATUS:
FULL TIME
PART TIME
NOT EMPLOYED
EMPLOYER: ___________________________________
OCCUPATION: ___________________________________
EMERGENCY CONTACT: NAME ______________________________ EMERGENCY PHONE(
)_______-__________
: (
)
YOUR PREFERRED PHARMACY
PLEASE LIST NAME, LOCATION AND/OR PHONE NUMBER
__________________________________________________________________________________________________
**************************************************************************************************
PRIMARY INSURANCE: _________________________________________
PRIMARY CARDHOLDER NAME: _______________________________________
CARDHOLDER SSN: _______-_______-_______
CARDHOLDER BIRTHDATE: ______/______/_______
SECONDARY INSURANCE: _______________________________________
PRIMARY CARDHOLDER NAME:________________________________________
CARDHOLDER SSN: _______-_______-_______
CARDHOLDER BIRTHDATE: ______/_______/______
Please Initial: ___________ I acknowledge I have received a copy of the Financial Policies form and have
access to the form at

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