<p> DR. NIGRO FOOT AND ANKLE CARE CENTERS</p><p>PATIENT INFORMATION Name (First)______(Middle)______(Last)______Address:______City/State:______Zip Code:______Home Phone # (______)______Cell Phone (____)______Work Phone (___)______Birth date______Age______Sex: Male / Female Social Security number: ______Marital Status: Single / Married / Divorced / Widow/Widower Email Address:______Employer:______Occupation:______(If Patent is a minor, please give name of parent or guardian who is financially responsible) Name of Parent/Guardian ______Phone Number (___)______Who is your Primary Care Physician? ______Date of last visit?______Physician's Phone ______How did you hear about us? Friend ______Physician_____ Yellow Pages______Internet ______Have you visited our website? Yes or No Have your visited Our Doctor Store? Yes or No Height ______Wt______Shoe size ______Last Blood Pressure _____/_____ If you are diabetic: What is your last Fasting Blood Sugar ______Last HgA1C ______</p><p>YOUR Past Medical History Arthritis No Yes Infections No Yes Asthma No Yes Kidney Disease No Yes Blood Transfusion No Yes Liver Disease No Yes Cancer No Yes Neurological Disorder No Yes Diabetes No Yes Polio No Yes Epilepsy No Yes Psychiatric Problem No Yes Stomach (Ulcers) No Yes Respiratory Disease/TB No Yes Heart Disease No Yes Sleep Apnea No Yes Hepatitis No Yes Stroke No Yes HIV/AIDS No Yes Thyroid Disease No Yes High blood pressure No Yes Vascular Disease No Yes Cholesterol No Yes Blood Clots No Yes Other ______Anxiety/Depression No Yes</p><p>Surgeries / Hospitalizations (Year and Complications) ______</p><p>Have you ever had general anesthesia? No Yes Have any problems with anesthesia? No Yes Describe:______</p><p>Allergies to medications: (circle) NO Allergies Penicillin Tetracycline Aspirin Sulfa Cortisone Iodine Novacaine Adhesive Latex Caffeine Sea Food other______</p><p>Medications (please list or provide a copy to the office staff) ______</p><p>Pharmacy name and location______Significant Past Family History</p><p>Does anyone in your family have a history of (please circle) Diabetes High Blood Pressure Cancer Obesity Heart Disease Arthritis Stroke Thyroid Disorder Gout kidney issues Asthma Bleeding Disorder</p><p>FAMILY AND SOCIAL HISTORY: Are you pregnant? No Yes When was your last tetanus immunization? ______Do you smoke? No Quit Yes ______packs a day Do you use any other tobacco products? No Yes What? ___ Do you use alcohol? No Yes Socially Daily Do you exercise No Yes ______Do you take any addicting drugs? No Yes</p><p>Foot and Ankle Health Information Why are you seeing the doctor today?______Describe injury/present illness in detail ______How long has it been bothering you? ______Current problem is the result of a(n): Work ______Accident ______Have you received any treatments for this condition? ______</p><p>Consent for Consent for Care: I hereby give my consent for treatment to Dr. Nigro Foot and Ankle Care (Dr. Jeff Nigro, Dr. Nicki Nigro and Dr. Jesse Mytinger) including treatment or services, and which may include but not limited to examination, x-rays, injections, photos and treatments which my physicians and I agree are necessary.</p><p>Authorization to Obtain/Release Medical Records: I authorize Dr. Nigro Foot and Ankle Care, or any person designated by them, to obtain/release copies of my medical records to any physician or institution for the purpose of evaluation and/or comparison with examination and testing being performed on me/my dependent. </p><p>Authorization to Pay Benefits to Physician: I hereby authorize payment to Dr. Nigro Foot and Ankle Care for services rendered to me or my dependents. I also authorize this office to release any information necessary to expedite insurance claims. I understand that I am responsible for and balance not covered by insurance and/or collection costs and legal fees incurred in any attempt to collect said balance. I assign all medical and or surgical benefits to Dr. Nigro Foot and Ankle Care.</p><p>Authorization to Leave Message: I hereby authorize Dr. Nigro Foot and Ankle Care to leave a message regarding pending appointments and/or tests at my residence. You may notify me of lab/test results, by leaving a message (Check all that applies.) ____on my answering machine/home voice mail; ____with my spouse; _____a family member (Please specify name of the family member) : ______</p><p>I understand that the doctors will give no more than 90 prescription pain medication if needed. If more than 90 are requested or needed, I will be referred to a pain specialist.</p><p>I have been given an opportunity to read the Health Insurance Portability & Accountability Act of 1996 (HIPAA)</p><p>Signature:______Date:______</p><p>Physician Signature: ______Date: ______</p>