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POPLAR PODIATRY
1038 S YATES
MEMPHIS, TN 38119
PATIENT DEMOGRAPHICS/INSURANCE FORM
Today's Date:
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Patient's First Name:  
M.I:
Last Name:  
Date of Birth:  
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Gender:
Social Security #
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Race:
select
Ethnicity:
Preferred Language:
Address:
City:
State:
Zip:
Preferred Contact Method:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
 
Confirm Email:
 
Employment Status:
Employer:
Occupation:
Student Status:
Marital Status:
Spouse Name:
Spouse Employer:
Were you referred by a Doctor?
Referring Doctor:
How were you referred to our clinic?
Emergency Contact Name:
Relation to Patient:
Emergency Contact Home Phone:
Emergency Contact Work Phone:
Responsible Party:
Responsible Party Phone Number:
Responsible Party Address:
INSURANCE
Primary Insured Name:
Primary Insured's Employer:
Primary Insured DOB:
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Primary Insured's SSN:
- -
Patient Relationship to Primary Insured:
Medical Insurance:
Member ID/SS#:
Group Name or #:
Secondary Insurance:
Member ID/SS#:
Group Name or #:
Secondary Subscriber Name:
Secondary Subscriber DOB:
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Patient Relationship to Secondary Ins. Subscriber:
Self Pay:
Self Pay Patients must pay in full at the time of the service. Insurance will be verified and accepted, however, the co-pay, deductible and/or any non-covered charges must be paid in full at the time of the visit.
MEDICAL HISTORY
Reason for today's visit?
Date of last exam?
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By whom?
What is your main concern about your feet/legs?
Which foot is bothering you?
How long have you had the current problem/condition?
Do you wear orthotics?
If yes, how old are they?
What have you done to treat the problem yourself?
Primary Care Provider(PCP):
Dr's Phone:
Are you currently taking any medications?
(including oral contraceptives, aspirin, otc and/or herbal meds)
If so please list:
Type Medication Name Medication Details
Do you have allergies to any medications?
If so please list:
Type Allergy-Medication Name Reaction Details
List all surgeries and/or hospitalizations you have had:
 
Are you pregnant or nursing?
Please List: Your Height in inches:
Your Weight in lbs:
Check any of the following podiatry conditions you have had:
Check any of the following medical conditions you have had:
Remarks: If any of the above boxes are checked, please explain including date of onset, severity, persistency of symptoms, and your physician currently caring for the problem:
 
FAMILY MEDICAL HISTORY
Please Note any family history (Parents, Grandparents, Children, Siblings, Living or Deceased) for the following:
DISEASE/CONDITION
Yes / No / ?
RELATIONSHIP TO YOU
Bunions
Flat Feet
Hammertoes
High Arches
Skin Disease
Varicose Veins
Arthritis
Cancer/Tumor
Diabetes
Heart Trouble
High/Low Blood Pressure
Kidney Disease
Lupus
Thyroid Disease
Other
IMMUNIZATION HISTORY
Disease Immunization Date
SOCIAL HISTORY
(This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.)
Smoking Status:
Do you use tobacco products?
If yes, type/amount/how long:
Do you use illegal drugs?
If yes, type/amount/how long:
Do you consume alcohol?
If yes, type/amount/how long:
Have you ever been exposed to or infected with:
REVIEW OF SYSTEMS
Do you currently, or have you ever had any problems in the following areas:
Constitutional
Fever, Weight Loss/Gain
Integumentary (Skin)
Neurological
Headaches
Migraines
Seizures
Psychiatric
Allergic/Immunologic
Ears, Nose, Mouth, Throat
Allergies/Hay Fever
Sinus Congestion
Runny Nose
Post-Nasal Drip
Chronic Cough
Dry Throat/Mouth
Respiratory
Asthma
Chronic Bronchitis
Emphysema
Vascular/Cardiovascular
Diabetes
Heart Pain
High Blood Pressure
Vascular Disease
Gastrointestinal
Diarrhea
Constipation
Genitourinary
Diarrhea
Bones/Joints/Muscles
Rheumatoid Arthritis
Muscle Pain
Joint Pain
Lymphatic/Hematologic
Anemia
Endocrine
Thyroid/Other Glands
If you answered Yes to any of the above or have a condition not listed, please explain:
 
If you answered question (?) to any of the above, please explain:
 
I, the patient/guardian/responsible party, have accurately and truthfully completed the information listed on this form. I agree that all fees incurred are my responsibility regardless of insurance coverage. I acknowledge that I have received a "Notice of Privacy Practices" regarding the use and disclosure of my health information (Form is available at front desk or printable from our website).
By clicking "Yes" below you will have electronically signed this form
Your Name:
Date:
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