Patient Information - Dr. Margaret L. Meredith, DPM Total Foot Care

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Dr. Margaret L. Meredith, D.P.M. Total Foot Care of the New River Valley

194 Woodland Drive Pearisburg, VA 24134 Phone (540) 921-2202 Fax (540) 921-2149

Section I: Date:

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Patient Information

Last Name:______________________ MI___ First Name:________________________ I Preferred Name: ________________________________________________________ Date of Birth: ___/___/_____ Social Security Number: _____-____-_____ Sex: M / F Age:____ Weight_____lbs Height___ft___in Marital Status: [ ] Single [ ] Married [ ] Widowed [ ] Divorced Shoe Size____ Family Doctor:______________________ Doctor’s Phone Number: (____) ____-______ Please Provide Your Preferred Pharmacy: ______________________________________ Employer: _______________________ Occupation:_________________________ Why Are You Being Seen Today? (Describe Your Foot Problem):___________________ _______________________________________________________________________ _______________________________________________________________________ Whom May We Thank For Referring You: ____________________________________

Contact Information

Address:_________________________________________________________________ _________________________________________________________________ City:_______________________ State:_____________________ Zip:______________ Home Phone: (____) ____-_____ Cell Phone: (____) ____-_____ Email: __________________________________________________________________ The Best Time to Contact Me Is: _________________________ [ ] AM [ ] PM I Prefer to be contacted on/by [ ] Home Phone [ ] Cell Phone [ ] E-Mail If you selected your Cell Phone how do you prefer to be contacted [ ] Call [ ] Text

Patient Name:__________________________________ DOB:__________

Home Phone: (____) ____-_____

Emergency Contact

Last Name:______________________ MI___ First Name:________________________ Cell Phone: (____) ____-_____ Address:_________________________________________________________________ _________________________________________________________________ City:_______________________ State:_____________________ Zip:______________ If Self please move to the next section

Responsible Party

Relationship to Patient: [ ] Self [ ] Spouse [ ] Parent [ ] Other If Other please specify:_____________________________________________________ Last Name:______________________ MI___ First Name:________________________ Date of Birth: ___/___/_____ Social Security Number: _____-____-_____ Address:_________________________________________________________________ _________________________________________________________________ City:_______________________ State:_____________________ Zip:______________ Home Phone: (____) ____-_____ Cell Phone: (____) ____-_____ Email: __________________________________________________________________ Employer: _______________________ Occupation: _________________________

Insurance Information

Who Provides Your Insurance: [ ] Self [ ] Spouse [ ] Parent [ ] Responsible Party If Self or Same as Responsible Party please move to the next section

Patient Name:__________________________________ DOB:__________

Last Name:______________________ MI___ First Name:________________________ Date of Birth: ___/___/_____ Social Security Number: _____-____-_____ Address:_________________________________________________________________ _________________________________________________________________ City:_______________________ State:_____________________ Zip:______________ Employer: _______________________ Occupation: _________________________

Medical History

Do you or have you ever been treated for: (Please Check ALL That Apply) [ ] Stroke [ ] Phlebitis [ ] Anemia [ ] Diabetes [ ] Gout [ ] Sciatica [ ] Arthritis [ ] Epilepsy [ ] Heart Attack [ ] Vascular Disease [ ] Poor Circulation [ ] Kidney Disease [ ] Osteoporosis [ ] Lyme’s Disease [ ] Headaches [ ] Nerve Disorder [ ] High Blood Pressure [ ] A Heart Condition [ ] Eyes: Glaucoma/manicular deg.

[ ] Keloid/ Thick Scar [ ] Alzheimer’s [ ] Rheumatic Fever [ ] Hearing/ Ear Disorder [ ] Psychiatric Disorder [ ] Asthma [ ] Hepatitis [ ] Dark Urine [ ] Cancer [ ] Lung Disease [ ] Liver Disease [ ] Chronic Lt. Stool [ ] Stomach Ulcer [ ] Tuberculosis [ ] Thyroid Problem [ ] Unexplained Weight Loss [ ] HIV/AIDS Others:_________________________________________________________________ Do you have vascular grafts? (if yes explain below) Do you have joint implants? (if yes explain below) Do you have replacement heart valves? Are you now under active Chemo Therapy? [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] No [ ] No [ ] No [ ] No [ ] No Have you had any other serious illness? (list below) Have you ever been hospitalized or been under 24 hour medical care? [ ] Yes [ ] No I Had Surgery For: On Date of: With Complications of: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

Medical History Continued

Patient Name:__________________________________ DOB:__________

Please list the relationship of family members who have had: Diabetes:____________________________ Foot Problems:______________________ Arthritis:____________________________ Heart Attack:_______________________ Stroke:______________________________ High Blood Pressure:_________________ Cancer:_____________________________ Birth Defects:_______________________ Number of past child births_____ Are you currently Pregnant? [ ] Yes [ ] No Are you slow to heal after cuts? Do you smoke now? [ ] Yes [ ] No Any abnormal bruising, bleeding, or cuts? [ ] Yes [ ] No [ ] Yes [ ] No Packs/ Day ___ Years__ Did you ever smoke? [ ] Yes [ ] No Packs/ Day ___ Years__ If you quit when did you do so? _____________________________________________ Do you consume alcoholic beverages? Circle one: None Rarely Moderately Daily Quit Do you consume Recreational Drugs? Circle one: None Rarely Moderately Daily Quit Are you currently taking any medications? [ ] Yes [ ] No If yes please list below Medications: Frequency: For Treatment Of: If you need more space to list your medications write on the back or ask the receptionist for paper. Are you currently taking your medications as prescribed [ ] Yes [ ] No Do you have any allergies with a history of skin reaction or other outward reaction or sickness following an injection, oral, or topical administration? Check all that apply Yes No Reaction to Medication Penicillin Other antibiotics (list below) ___ ___ ____________________________ ___ ___ ____________________________ Empirin / Tylenol (if yes, Circle) Aspirin, Advil, Aleve, or Motrin (Circle) ___ ___ ____________________________ Celebrex, Bextra, Vioxx (Circle) ___ ___ ____________________________ ___ ___ ____________________________ Other Pain Medicines (list below) Morphine Codeine Demerol Other Narcotics (list below) Novocaine ___ ___ ____________________________ ___ ___ ____________________________ ___ ___ ____________________________ ___ ___ ____________________________ ___ ___ ____________________________ ___ ___ ____________________________

Patient Name:__________________________________ DOB:__________

Other anesthetics (list below) Sulfa Drugs ___ ___ ____________________________ ___ ___ ____________________________ Adhesive tape ___ ___ ____________________________ Shrimp, Iodine, or Merthiolate ___ ___ ____________________________ Others: _________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

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