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Advanced Podiatry Specialists

502 N 40th Ave, Ste 1, Yakima, WA 98908

509-965-0625 (p) 509-966-4967 (f) www.advanced-podiatry.com Account Information Primary Insurance Insurance Co.: _________________ ID/Acct#: _____________________

Patient Information Date: __________________ Minor Single Married Divorced Widowed Male Female

Group # _____________________ Patient Name: ______________________ Address: ___________________________ ___________________________________ Birthdate: __________________ Age:_____ Soc. Sec.#: __________________________ Home Phone _________________________ Primary person on Acct:__________ _____________________________ Birthdate: _____________________ Soc. Sec. #: ___________________ Secondary Ins.: ________________ ID/Acct# ______________________

Work Phone __________________________ Occupation:______________________ Cell Phone ________________________ Primary language spoken: _____________ Message Phone ____________________ Email ______________________________ In the event of an emergency, who should we contact? __________________________ Relationship:____________________ Phone ( )________________________ )_____________________

Primary Doctor______________________ Phone (

How did you find out about us? ________________________________________ If patient is a minor, please list yourself as responsible for account due to HIPAA rules so we may release account information to you. Also provide proper documentation if you have power of attorney regarding patient listed on account. I understand it is my responsibility to inform the office of any changes in my or my dependants information that I have provided. I understand that honest and complete answers to each question stated are important to the provision of my medical care and I have answered them to the best of my ability.

Patient Medical History

Allergies List Reaction Below Reason for visit today: ______________________ Penicillin Tylenol Adhesive tape _________________________________________ Morphine Aspirin Iodine/Dye Codeine Demerol Shellfish When did your main problem begin?:____________ Other Antibiotics? __________________________________________ Other Narcotics? Novocaine Was this caused by an injury?:_________________ Other Anesthetics? __________________________________________ Ibuprofen, Advil,Aleve Motrin Do you have any other foot problems that may need attention? Other pain remedies? _________________________________________________ Sulfa Drugs Other? Have you had any foot or ankle surgeries in the past?_________ If yes, When? _____________ Where? ____________________ Who was the attending Doctor? __________________________ Past History: (please circle all that apply) Ankle pain, athletes foot, fungal nails, bunions, corns and calluses, cramps or numbness in feet or legs, tired feet, flat feet, foot pain , arch or heel pain, ingrown toenails, plantar warts, swelling in ankles or feet, ankle or foot ulcers, broken ankle or foot bones, hammertoes, gait (walking) problems, neuroma, knee pain. Other: _____________________________________________________

Did you previously or do you now wear: Shoe inserts or custom orthotics? Still using them Y/N Did they help Y/N Were they dispensed by a doctor or over the counter? Is your first step out of bed painful? Y/N How long does it take to subside? Do you get leg or foot cramps during the day? Y/N during the night? Y/N Percent of waking hours on your feet : 20 %, 40%, 60%, 80%, 100% List any sports or extra curricular activities you are involved in:____________________ ______________________________________________________________________ Does foot pain limit any of your activities?: _______ Please explain:________________ ______________________________________________________________________ Do you have pain even when not on your feet? Y/N Do you have or have you ever been treated for (circle all that apply): Stroke, phlebitis, diabetes, hepatitis, gout, sciatica, alzheimers, epilepsy, glaucoma, asthma, cancer, heart attack, vascular disease, poor circulation, liver disease, arthritis, rheumatic fever, keloid/thick scar, nerve disorder, kidney disease, lung disease, stomach ulcer, high blood pressure, any heart condition, headaches, anemia, osteoporosis, lyme's disease, hearing/ear disorders, psychiatric disorders, thyroid problem, tuberculosis. Other?: ____ Any family members who have had any of these problems in the past? Please List.

HT ______ WT _______ Shoe Size _______ (Wide)/(Narrow) Any Chance of Pregnancy? _____ Are you Claustrophobic? ______

Any other films taken anywhere? _____, If yes, Where? _________________ What Pharmacy do you use? ______________________ List Current Medications you are taking on a daily basis: _________________________ ______________________________________________________________________ ______________________________________________________________________ Do you have vascular grafts? Do you have joint Implants? Do you have replacement heart valve? Have you or are you under active chemotherapy? Have you been recently hospitalized? If yes, Where? _____________________ Anything else you want to tell the Doctor? _____________________________________ ______________________________________________________________________ Medicare only Lifetime Authorization for Medicare: I request that payment under the medical insurance program be made to Dr. Curtis Holden or Michael Lee, DPM, on any bills for services furnished to me during the effective period of this authorization. I also authorize the aforementioned providers to release for payment purposes to the Soc. Sec. Admn or its intermediaries or carriers any information needed for this claim or any related Medicare claims. I further permit this authorization to be used in place of the original. Signature: ____________________________________ Date: ____________________ All Sign I authorize the staff to perform any necessary services needed during diagnosis and treatment of myself or my dependant. I also authorize the release of any information needed to process insurance claims. I assign directly to Dr. Curtis T. Holden or Michael Lee, DPM all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for any and all services provided whether or not my insurance pays. Signature: _____________________________________ Date: ___________________

PAYMENT & INSURANCE We are preferred providers for Blue Cross, Blue Shield, and Group Health. We accept most insurances, Medicare and Medicaid. VISA and Mastercard accepted.

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Advanced Podiatry Specialists

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