Patient Information

Patient's Name

Date of Birth

Sex

Female

Male

SS#

Marital Status

Age

Shoe Size

Patient Address

Address

Apt

City

State

ZIP

Patient Contact

Home Phone

Best number to contact you

Home Phone

Cell Phone

Work Phone

Cell Phone

Work Phone

Patient Contact

Employer

Occupation

Primary Insurance

Secondary Insurance

Primary Insured

Primary Insured's DOB

ID#

Group#

Primary Care Physician (PCP)

PCP Ph#

Date of Last PCP Visit

Hospital

Name & Ph# of any other treating doctors

Who should we thank for referring you?

Emergency Contact

Emergency Contact Ph#

Relationship

Reason for visit

Please describe your footlankle problem

HISTORY - Personal - Social - Family - Medical - Surgical

If appropriate. Name & phone # of Legally Responsible Person

Special considerations due to cultural or religious beliefs

Yes, specify

Language

English

Spanish

Other

Translator needed

Race

American Indian/Alaska Native

E. Black/African Amercan Native

Hawaiian/Pacific Islander

Caucasian

Asian

Decline to answer

Other

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Decline to answer

Limitations

None

Hearing

Vision

Cognitive Impaired

Mobility

Illiterate

Social History

Smoking

No. Never

Quit, as of

Yes - Type:

Cigarettes

Cigars

Pipe

Chewing tobacco/snuff

# packs/ea Per day - week

Alcohol

Yes - Type:

Frequency

Occasional

Recreational Drug Use/Abuse

Denies Use

Admits Occasional Use

Exercise

Not Regularly

Walking Treadmill

Aerobics

Golf/Tennis/Jogging

Weight Lifting

Other

Caffeine

Yes - Amount/day

Type

Family History

	Living	Decesed	Explanation
Mother
Father
Brother
Brother
Sister
Sister
Childern - # of

Allergies

No Known Allergies

Penicillin

Sulfa

Codeine

Latex

Aspirin

Food, specify

Other

Medical Diagnosis & Conditions

Significant Surgical & Invasive Procedures

Date	Description

Medication List

Date	Medication, Herbals, Vitamins, Over-the-counter drugs (For example: Lipitor)	Strength (10 mg)	Dose (1 tab)	Frequency (1 x / day)

Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read or had the opportunity to read if I so chose) and understand the notice.

I have received information on the Education and Training of Dr. Mitchell

I, also, authorize Mitchell Foot & Ankle, PC to release any of my chart information to the following person(s). le spouse, mother, father, guardian, other reiatives. etc.

Assignment and Release

I hereby give permission to Dr. Mitchell and his associates/staff to administer treatment as necessary, for the ciagnosis and/or treatment of my footiankle condition.

I hereby authorize payment directly to Mitchell Foot & Ankle PC for services rendered by Dr. Mitchell and his associates/staff I understand and acknowledge that I am financially responsible for the entire services provided for myself or the above names. regardless of insurance coverage.

I authorize the above doctor and/or any provider or supplier of services in this office to release the information required to secure the payment of benefits I authorize the use of this signature on all insurance submissions.

Serving Chicagoland
and Surrounding Suburbs

New Patient Submission Form

Patient Information

Patient Address

Patient Contact

Patient Contact

Reason for visit

HISTORY - Personal - Social - Family - Medical - Surgical

Social History

Family History

Allergies

Medical Diagnosis & Conditions

Significant Surgical & Invasive Procedures

Medication List

Acknowledgement of Receipt of Notice of Privacy Practices

Assignment and Release

Mitchell Foot & Ankle

Find Us on

Serving Chicagoland and Surrounding Suburbs

New Patient Submission Form

Patient Information

Patient Address

Patient Contact

Patient Contact

Reason for visit

HISTORY - Personal - Social - Family - Medical - Surgical

Social History

Family History

Allergies

Medical Diagnosis & Conditions

Significant Surgical & Invasive Procedures

Medication List

Acknowledgement of Receipt of Notice of Privacy Practices

Assignment and Release

Mitchell Foot & Ankle

Find Us on

Serving Chicagoland
and Surrounding Suburbs