Bluegrass Regional Foot and Ankle Associates
Established Patient Medical Update with EMR
Name:_________________________________________________________________________
First
Middle
Last
Address _____________________________________ City _________ State_____ Zip________
Home Phone (___) ____-______
Age_____
Cell (___) ____-_____
Date of Birth ___/___/___
Work(___) ___-_____
SS# _____-_____-______
Parent / Spouse’s Name __________________________________________________
EMERGENCY CONTACT
Name___________________________________ Relationship_______________________
Phone (____)____-______
Which foot/ankle is it? RIGHT
Alternate Phone (____)_____-_______
LEFT
BOTH
What is your current foot/ankle problem?
___________________________________________________________
IF any changes in Insurance please specify:
Insurance Provider: _____________________________
Policy No. _____________________
Policy Subscriber (if other than patient) ____________________________________________
Relationship to patient ________________________ Subscriber’s Date of Birth __/__/__
I certify that the medical information that I have included on the previous forms is true and correct
to the best of my knowledge. I give permission to Bluegrass Regional Foot and Ankle Associates
to administer and perform such procedures as may be deemed necessary in the diagnosis and/or
treatment. I also understand and acknowledge that, to the extent medically necessary, I may be
administered and/or prescribed a controlled substance while receiving medical care and treatment,
in order to manage complaints of pain.
Patient/Guardian’s Signature_______________________________________ Date__________
Patient’s Name_________________________________________________ DOB__________
Medical Records / Privacy
At Bluegrass Regional Foot & Ankle Associates, we are committed to protecting the security and privacy
of your personal information. Medical records are the property of Bluegrass Regional Foot & Ankle
Associates, kept in a secure location, and are accessed for only purposes outlined by the Notice of Privacy
Practices. Records may be released or shared with other health care providers for your treatment. Patients
are entitled to one free copy of their medical records only after an authorization for release is signed.
Additional copies may be made for a fee.


I understand that Bluegrass Regional Foot & Ankle Associates may call my home and place of
employment for health care reasons, appointment reminders, to resolve billing issues, and mail
informational postcards to my home as well as billing information requested verbally by me.
I understand that Bluegrass Regional Foot & Ankle Associates may leave messages on my
answering machine regarding appointments and limited lab information, and that my email may also
be used for these purposes.
I acknowledge that Bluegrass Regional Foot & Ankle Associates will upon request make available a
copy of the Notice of Privacy Practices and Consent to Treat Information. I understand that I can edit any of
the above items.
Please list any other person(s) that we may release your medical information to:
_________________
___________________
_________________
_________________
BRFAA Provider Policy
Bluegrass Regional Foot and Ankle Associates (BRFAA) was established in January 2003 by Paul K.
Krestik, DPM and Daniel C. Albertson, ARNP. Dr. Krestik is a graduate of Scholl Podiatry School and
completed a surgical residency in Massachusetts. Daniel Albertson, a Certified Family Nurse Practitioner,
received his Masters Degree from the University of Kentucky in 2000 and has been practicing exclusively in
Podiatric Medicine since that time. In the course of your treatment with BRFAA, you may see either: Dr.
Krestik or Daniel Albertson. If you have a preference of provider, please notify our office staff and
we will make every effort to accommodate your preference.
I acknowledge that I have read and understand the information in sections 1 and 2. I further acknowledge
that if I have questions or concerns about BRFAA’s provider policy it is my responsibility to discuss this with
a representative of BRFAA.
____________________________________________________ __________________
Patient/Guardian Signature
Date
Bluegrass Regional Foot and Ankle Associates
“Serving the podiatric needs of Central & Southeastern Kentucky”
1105 West 5th Street, Suite 3 * London, KY 40741
Phone 606-862-9900 * Fax 606-862-8901
------------------------------208 Bellaire Drive* Nicholasville, KY 40356
Phone 859-887-8026 * Fax 859-887-0017
Payment Obligation Form
Your insurance requires:
___
Co-pay of $________ per visit. You will be responsible to pay this amt. for services
rendered today.
___
Co-Insurance of ______%. You will be responsible to pay this percentage for services
rendered today.
___
Multiple Insurance Carriers:
You will be responsible for any outstanding balance after the processing of claims by your
insurance carriers.
___
Claim submission:
Your insurance requires claims to be submitted prior to patient payment. After claims are
expedited, if there is a patient balance, you will be billed at that time.
___
I have not met my deductible and I agree to pay in full for services rendered today. (Amt.
due will be based on your insurance’s allowable fee schedule)
____
Self-pay/No insurance
I agree to pay in full for services rendered today.
Note: All unpaid balances will be subject to a $20.00 late fee.
This information has been explained to me and I fully understand and agree with this
payment obligation. I also understand that it is the policy of Bluegrass Regional Foot and
Ankle Associates that all co-payment, co-insurance, supply purchases and/or other patient
obligations are to be paid on the date of service being rendered.
_________________________________________________________________
Patient/Guardian Signature
Date
Electronic Medical Record
(PLEASE CIRCLE ANSWERS BELOW)
Primary Race:
Language:
White
English
Marital Status: Married
Black
Spanish
Hispanic
Other: ____________
Other: ______________________
Divorced
Single
Widowed
Separated
Primary Care Physician: ________________________MD, DO, NP, PA
Pharmacy:____________________________
Allergies: Do you have any drug allergies?
YES NO
Do you have seasonal/environmental allergies?
Do you have food allergies? YES NO
YES
NO
I am allergic to: Penicillin
Sulfa
Aspirin Cephalosporins
Erythromycin LATEX Iodine Adhesive Tape Novocaine/Lidocaine
OTHER Drug Allergies:__________________________________________
List of Food or Environmental allergies:_____________________________
Past Medical History: (CIRCLE YOUR Personal Medical History)
Aids/HIV Alcoholism
Appendicitis Asthma Cancer Diabetes Emphysema
Gout Hepatitis High Blood Pressure MS Pacemaker Pneumonia Seizures
Stroke Thyroid Disorder Ulcer(stomach)
OTHER:____________________________________________________________
Past Surgical (SX) History: (CIRCLE YOUR Personal Surgical History)
Amputation (toe) (foot) (leg) Angioplasty Ankle Sx Appendectomy Back Sx
C-section Eye Sx
Foot Sx Hip Replacement
Knee Sx
Nail Removal
Thyroid Sx Tonsillectomy Heart Surgery Vascular Sx Wisdom tooth removal
OTHER:____________________________________________________________
Family History: (CIRCLE your Blood Related Relatives Medical History)
Cancer
Depression
Diabetes
Genetic Disease
Heart Disease
High Cholesterol High Blood Pressure
Rheumatoid Arthritis
Stroke
OTHER:___________________________________________________________
Social History:
Alcohol Use
Illegal Drug Use
Smoking/Tobacco Use
Review of Systems:
Constitutional:
(CIRCLE Conditions/Problems that you CURRENTLY have)
Anxiety Dizziness Fever Headaches Nausea/Vomiting
Increased thirst Tiredness Vertigo Weight Gain Weight Loss
Cardiovascular: Ankle Swelling Cramp in Calf Cardiovascular Problems
Cold Feet Elevated BP Murmur Pacemaker Varicose Veins
Endocrine:
Dry Hair
ENT: Cough
Dry Skin
Extreme Thirst
Difficulty Hearing
Eyes: Wear Glasses
Unusual Fatigue
Difficulty Swallowing
Blurred Vision
Dry Eyes
Dry Mouth
Loss of Vision
GI: Blood is stool Constipation Diarrhea Heartburn (GERD) Hemorrhoids
Rectal Bleeding Vomiting Yellowing of Skin
Genitourinary: Kidney Dialysis Currently Pregnant Urinary Frequency
Immunologic: Arthritic Flare-up
Skin: Athletes Foot Blisters
Itchy Skin Leg Ulcers
Lymphatic: Calf Pain
Gout Attack
Hepatitis
Burning of Skin Dermatitis
Non-Healing Wounds Rash
Legs Swelling
Dry, Scaly Skin
Tingling Sensation
Water Retention
MSK: Back Pain Weakness in Legs Heel Pain
Hip Pain
Leg Cramps
Morning Stiffness
Muscle Tenderness
Neurological: Burning in Feet
Seasonal Allergies
Numbness
Paralysis
Joint Swelling
Seizures
Tingling
Psychiatric: Addiction - Alcohol Addiction - Drugs Anxiousness Depression
Memory Loss Panic Attacks
Emotional/Psychiatric difficulties
Respiratory: Difficulty Breathing
Shortness of Breath
Rx & OTC Medications
1) ____________________________
2) ____________________________
3) ____________________________
4) ____________________________
5) ____________________________
6) ____________________________
7) ____________________________
8) ____________________________
9) ____________________________
10) ___________________________
Dosage
______
______
______
______
______
______
______
______
______
______
Wheezing
How many times a day
once twice three other:
once twice three other:
once twice three other:
once twice three other:
once twice three other:
once twice three other:
once twice three other:
once twice three other:
once twice three other:
once twice three other:
Please List any other important medical information here:
Tuberculosis Screening Questionnaire
Due to OSHA (Occupational Safety and Health Administration) and CDC
(Center for Disease Control) guidelines, we are required to have all new and
established patients fill out the following form annually.
Full Name: ___________________________________________________________________
Address: _____________________________________________________________________
Phone #: ________________________
Date of Birth: _________________________
Have you ever had a positive TB test?
If yes, when? ____________________
Yes
No
Date of last chest X-ray: _________________
To your knowledge, do you currently have TB? Yes
No
To your knowledge, have you come in contact with any persons who have had TB
within the last 30 days?
Yes
No
Please indicate if you have had any of the following problems for 3 to 4 weeks or longer:
Chronic Cough:
Production of Sputum:
Blood Streaked Sputum:
Unexplained Weight Loss:
Fever:
Fatigue/Tiredness:
Night Sweats:
Shortness of Breath:
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
I understand that due to OSHA and CDC guidelines, if I have or may have TB, BRFAA has
the obligation to refer me to the Health Department and will not be able to see me until I
provide proof of a negative TB test.
I understand that I will be given a surgical mask to wear and quarantined until I have
transportation to the Health Department. I understand that it is my responsibility to notify
BRFAA of any changes in my health regarding TB.
_____________________________________________
Signature
____________________
Date