Last Name:*
First Name:*
Middle Name:
Phone Number*
DOB (YYYY/MM/DD):*
MaleFemaleOther
PHN:*
Address:*
City:*
Postal Code:*
Email*
Insurance provider:*
Occupation:*
Employer:*
Emergency Contact Name / Phone:*
How did you hear about us?*
Family Doctor:*
Phone:*
Reason for visit:*
Height:
Weight:
Shoe size:
Do you have any of the following conditions?
Acid Reflux
AIDS/HIV
Anxiety
Arthritis Osteo/Rheumatoid
Back pain
Bleeding disorders
Blood clot
Cancer
Cancer type:
Cholesterol
Circulation
Diabetes (Type 1/2)
Fibromyalgia
Gout
Heart Attack
Heart disease
Hepatitis A / B / C
Hernia
High blood pressure
Kidney problems
Liver problems
Lung problems
Lupus
Migraines
Osteoporosis
Prostate
Psoriasis
Stroke
Thyroid
Tuberculosis
Other conditions:
Adhesive tape
Aspirin
Codeine
Iodine
Latex
Local anesthetics
Metal
Penicillin
Other
Are you pregnant? YesNo
Do you exercise? YesNo
If yes, please describe:
Do you smoke? RegularSociallyNever
Do you drink alcohol? RegularSociallyNever
Any recreational drugs? RegularSociallyNever
List any past hospitalizations / surgeries:
1.
2.
3.
4.
5.
I certify that the above information is accurate and true, and I hereby consent to evaluation, diagnosis, and treatment of my medical condition by Dr.Matthew Bolshin, DPM. I understand that podiatrists are not covered by the Medical Services Plan (MSP) and I am responsible for full payment. I acknowledge that some services may be partially covered by MSP, and I authorize Dr. Bolshin to bill MSP for these services.
I agree*
Signature*:
Patient Name*:
Date*:
