Patient Information Form
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3Practice: Columbus Foot & Ankle, PC
Today’s Date:
__________________
Name: ___ ____________________________________
DOB: _______________ Chart Number: _____________
Sex:
Marital Status:
ingle
Married
Widowed
Divorced
SS#: ________________________
E-mail: _________________________________________ Spouse/Partner Name: _____________________________
Emergency Name: ______________________ Phone: ________________
E-mail newsletters, reminders, statements, etc.
Address: _______________________________________
City: _______________ State: _______ Zip: __________
Home #: __________________________ Cell #: _________________________ Other #: _______________________
Employer: _____________________________________
Phone: ________________________
Employer Address: ___________________________
City: _______________
State: _______ Zip: _________
Primary Insurance: ___________________________________________________Are you the insured?
Insured Information
Subscriber Name: __________________________
Relationship to insured:
Phone #: ________________________________
Sex:
DOB: ___/___/___
Address: ________________________________________________________________________
Policy ID: ___________________ Group ID: ____________________Employer: _____________________
Secondary Insurance: _________________________________________________ Are you the insured?
Insured Information
Subscriber Name: __________________________
Relationship to insured:
Phone #: ________________________________
Sex:
DOB: ___/___/___
Address: ________________________________
________________________________________
Policy ID: ___________________ Group ID: ____________________Employer: _____________________
How did you nd out about our practice?
Physician
Internet
Telephone book
Family member
Friend
Other: ________________________________________________
What is the reason for your visit today? _______________________________________________________________
Result of accident or work injury?
How long has this bothered you? 1 2 3 4 5 6 7
days
weeks
months
years
What treatments have you tried & have they been effective?
___________________________________________________________________________________________________
On a scale of 1-10 (1 being no pain and 10 being the worst) what is your level of pain? ___/10
The pain quality is:
ther:__________
PLEASE READ AND SIGN ON PAGE #3
The above information is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for
notifying the physician and/or medical staff of any and all updates to the information listed above.
Patient Initials: ________________
Date: ________________________
Rev 1/21/2015
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