Initial Office Visit Intake Form

North Scottsdale Foot & Ankle Center

Initial Office Visit Intake Form

Required Field

Personal Info

First Name

Last Name

Date of Birth (MM/DD/YYYY)

Contact Info

Mobile Phone

Email

Profile Continued

What is your address?

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What is your home phone number? (only answer this question if you don't use cell phone)

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In case of an emergency, who should we contact? (name, relationship to you, and phone number)

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Reason For Office Visit

What is the reason for your office visit?

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Did you injure your foot or ankle? If so, what happened and when did it happen?

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Have you seen another Podiatrist in the past? If so, when?

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Shoes

What size shoes do you wear?

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What types of shoes do you like to wear?

Activity Level

Are you on your feet a lot during the day?

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What type of exercise do you like to do?

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Medical History

If you now have or you have ever had any of the following, please check the box.

Arthrtitis

Asthma

Blood Clot

Blood Disease

Cancer

COPD

Depression

Diabetes

Fibromyalgia

GERD/Reflux Disease

Gout

Heart Disease

High Blood Pressure

High Cholesterol

Kidney Disease

Liver Disease

Low Back Pain

Mental Health Disease

Neuropathy

Stroke

Thyroid Disease

Medications

What medications are you currently taking? Include dosage.

Do you have any known drug allergies? If so, describe your reaction.

Past Surgeries

List your past surgeries with estimated dates.

Family History

Do you have a family history of medical conditions (Diabetes, Gout, Heart Disease, Cancer, other), please include disease and your relationship to them.

Social History

Are you a current smoker?

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Do you drink alcohol?

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Pharmacy & Primary Physician

What is your Pharmacy name, address, and phone number?

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Who is your primary care physician?

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Referral

Whom can we thank for referring you to our office?

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