Dr. Flynn Sherick, D.P.M. and Dr. Michael Reed, D.P.M.
Ankle and Foot Care Clinic—2831 Foot Missoula Road, Ste 302—Missoula, MT 59804
Patient Registration and Financial Agreement
Full Name______________________________________Name you prefer to be called __________________
Previous/Maiden Names____________________________________________________________________
Address___________________________________________________City/Zip______________________
Home Phone #________________Cell Phone #_________________Work Phone________________________
Date of Birth_________________________ Social Security #________________________Shoe Size_____
Height_________________Weight___________________Occupation_______________________________
Employer & Phone #______________________________Full/Part Time
Spouse’s name_____________________________ Spouse’s Social Security____________________________
Spouse’s Employer and phone________________________________________________________________
Parent’s name if patient is a minor _______________________Parent’s Employer & Phone___________________
Emergency Contact Name:_______________________________ Emergency Contact Phone_________________
Medicare #_____________________________________Medicaid #________________________________
If Medicaid, Passport Provider’s name is_________________________________________________________
Insurance Company & Address ____________________________________________________________
Name on insurance, ID # and Group #__________________________________________________________
Second insurance________________________________________________________________________
Name on second insurance, ID # and Group #_____________________________________________________
If there is an attorney on your case, please provide their Name__________________________________________
And Phone #____________________________
Who may we thank for referring you to us?_______________________________________________________
Have you had any medical treatment on your feet or ankles? ___________________________________________
Name of your medical physician ______________________________________________________________
I give permission to Dr. Sherick and Dr. Reed to examine me and to administer medical treatments he discusses with me and
that I agree to. I understand that I’m solely responsible for this consent and for payment of all services that are not paid by
my insurance. I will pay the balance after my insurance processes within ten days of processing in one lump sum payment by
cash, check, or credit card. I understand payment arrangements are available to finance payments through Care Credit. I will
speak with Annette or Suzanne if I need to make payments. A balance beyond 60 days of date of service will be charged
finance charges and late fees. I assign all benefits to Dr. Sherick and Dr. Reed. This assignment will remain in effect until
revoked by me in writing. I hereby authorize Dr. Sherick and Dr. Reed to release information to the insurance company if
necessary. Due to sanitary issues, medical supplies are not returnable if used. If you have questions about the prices of
supplies, please inquire before leaving the office with the supply item. Please give 24 hour’s notice of appointment
cancellation. Cancellations without notification are subject to charge. I understand that in the event any unpaid balance is
placed for collections with any third party collection agency, a fee of 50% of the unpaid balance will be added to the total
amount due. This amount shall be in addition to any other cost incurred directly or indirectly to collect amounts owed under
this agreement such as court costs, attorney fees, late fees, and other fees so stated elsewhere. The authorized fee of 50% and
the additional costs and charges listed above represent the actual costs incurred by Dr. Sherick and Dr. Reed to collect
amounts owed under this agreement and a corresponding decrease in expected revenue resulting from the signer’s failure to
pay as specified in this agreement.
Signature________________________________________________________________Date__________
As the party responsible for medical decision making for the child above, I hereby give my consent to Drs. Sherick and/or
Reed to render both emergency and non-emergent healthcare services both in and out of my presence.
Signature of parent/legal guardian_________________________________Date_____________Update_______
 I have received and reviewed the Notice of Privacy Practices ___________________
(initials)
____________________
(date)
 You have my permission to leave messages on my voicemail/answering machine ___________
______________
(initials)
(date) 1/14
Ankle & Foot Care Clinic
406-721-1171
Flynn Sherick, DPM
Michael Reed, DPM
HISTORY OF YOUR PRESENT ILLNESS
Name______________________________________Date_____________Age______
Name of the doctor that sent you here_______________________________________
Date and time of injury or onset of problem___________________________________
Where were you when injury occurred_______________________________________
Have you had x-Ray/MRI/CT/Other test, surgery, injection, procedure for this? Y
N
Where____________________________________________________
Please call 721-1171 so records can be acquired BEFORE your appointment
Have you been to the Emergency Room for this problem? Yes or No
If yes: Date seen: ________________ Which Hospital:_________________________
Your Employer: __________________________ Occupation:____________________
Is this a work-related injury? Yes or No
(If no, please go to Chief Complaint.)
Date Last Worked: ________________________
Are you on light duty for this problem? If so please describe: _____________________
Is an attorney involved with your health care? If yes, the name:____________________
CHIEF COMPLAINT:
Reason you are being seen today:_________________________________________
HISTORY OF SYMPTOMS:
1.Where is your pain or problem?__________________________________________
2. When did it start?_____________________________________________________
3. Is it:
4. Is it:
Sharp
Mild
Burning
Dull Aching
Moderate
Severe
Throbbing
5. When does it occur? Morning
After Exercise
Night
6. Is it:
Getting Worse
Getting Better
Constant
Intermittent
During Exercise
Staying the Same
7. Describe what makes it better___________________________________________
8. Describe what makes it worse___________________________________________
9. Do you have:
Swelling
Numbness Bruising Tingling
COMPREHENSIVE HISTORY (3 pages)
NAME:______________________________________________ Age:______ Male
Female
Name of your primary care physician______________________________________________
Name of your cardiologist_______________________________________________________
REVIEW OF SYSTEMS: Circle your medical problems from the list below. If none, please circle NONE here.
Weight loss or gain
Fatigue
Blurry/double vision
Ringing in ears
Hearing loss
Sinus congestion
Bloody nose
Loss of taste
Dry mouth
Sore throat
Ulcers
Diabetes
Neuropathy
Hearing Device
Circulation problems
Pulmonary embolism
Blood clots
High Blood Pressure
Cancer or tumors
Lung Disease
Hepatitis
HIV/Aids/ARC
Sleep Apnea
Chest pain
Irregular heart beat
Shortness of breath
Trouble breathing
Cough
Coughing blood
Upset stomach
Indigestion/GERD
Diarrhea
Bloody stool or urine
Kidney problems
On dialysis
Frequent urination
Burning urination
Joint pain or stiffness
Muscle weakness
Rashes or sores
Numbness
Poor balance
Anxiety
Depression
Hair loss
Excessive thirst
Easy bruising
Food allergies
Seasonal allergies
Heavy drinking
IV drug use
Abnormal EKG
Alcoholism
Anesthetic reactions
Arthritis/RA/Osteo
Asthma
Back or spine
problems
Bladder
Bone
Brain
Bronchitis
Balance problems
Change in gait
Dizziness
Chronic constipation
Clogged arteries
Ears
Eyes
Emphysema
Fainting
Fever
Foot skin infections
Frequent colds
Frequent headaches
Gall bladder
Genitals
Gout
Intestines
Jaundice
Kidney failure/stones
Latex allergy
Liver
Lymph nodes
Malaria
MS
Nervous breakdown
Nerves
Nose
Pain from thick nails
Palpitations
Paralysis
Pneumonia
Poor appetite
POSSIBLY PREGNANT
Recurrent
Nausea/vomiting
Vomiting blood
Bone infections
Rheumatic fever
Seizures/convulsions
Sjogren’s
Skin
Spleen
Stomach
Swollen ankles
Steroids
Throat
Tuberculosis
Vascular disease
DVT
RSD/CRPS
MRSA
Surgery complication
Osteoporosis
Staph infection
Mental illness
Fibromyalgia
Pregnancies
Complicated Births
Developmental
disabilities
Exposure to
chemicals/toxin/dust
Other:
Comprehensive History
Page 1 of 3
Please go to next page
Medication Allergies:
If none, please circle this “NONE”
1. Aspirin Allergy?______________
2. Penicillin allergy?_____________
3. Latex allergy?_________________
4. Local anesthetic allergy?_______
5. Shellfish or iodine allergy?______
Medications you take, include over-thecounter and herbals and vitamins
If none, please circle this “NONE”
Drug name, dose, frequency, why taken:
1.________________________________________
6.___________________________
2.________________________________________
7.___________________________
8.___________________________
3.________________________________________
9.___________________________
4.________________________________________
10.___________________________
11.__________________________
5.________________________________________
12. Other_______________________
6.________________________________________
Previous Surgeries:
If none, please circle this “NONE”
1.____________________________________
2.____________________________________
7.________________________________________
8.________________________________________
9.________________________________________
3.____________________________________
4.____________________________________
5.____________________________________
10._______________________________________
Name of your pharmacy:
6.____________________________________
Comprehensive History Page 2 of 3
Please turn to next page to finish your history
FAMILY HISTORY
If your birth family history is unknown, please write “unknown” here__________________
Does Anyone is your family have: Please circle:
Heart Disease
High Blood Pressure
Diabetes
Stoke
Cancer
Lung Disease
Circulatory Disease
Vascular Disease
Is your father living or deceased
Cause of death_________________________
Is your mother living or deceased
Cause of death_________________________
Number of brothers _________Number deceased______Cause of death_________________
Number of sisters ___________Number deceased______Cause of death_________________
SOCIAL HISTORY:
Marital Status:
Single
Married
Divorced Widowed
Live alone?
Yes
No
Occupation___________________________________________________________________
Do/did you smoke or use smokeless tobacco now or ever?
Yes
No
How much___________________________
How long___________________________
If you have quit tobacco, how long ago____________________________________________
Do you drink alcohol?
Yes
No
How much_____________________
Patient Signature_______________________________________Date__________
Reviewed by ____ ____________________________________DPM Date_______________
_________________________________________DPM Date_______________
_________________________________________DPM Date_______________
_________________________________________DPM Date_______________
_________________________________________DPM Date_______________
Comprehensive History Page 3 of 3
Patient Registration, 1/19/14