Jacksonvillefootdoctors.com

Date: / / Name of Family Physician: Patient Name: Marital Status: Sex: M F Home Address: Apartment/Lot #: City: State: Zip Code: Home Phone: ( ) Cell Phone: ( ) Social Security Number: Date of Birth: Age: Employer: Phone Number: ( ) Spouse/Guardian Name: Social Security Number: Address (if different from patient): Date of Birth: Home Phone: ( ) Cell Phone: ( ) Employer: Phone Number: ( ) Patient or Authorized Persons Signature I authorize release of any medical information necessary to process this claim and request payment of government benefits to the undersigned physician or supplier for services. I further agree to pay for all services not pain by my insurance company. In the event that this account goes to a collection agency I agree to pay all collection fees incurred up to 40%. _____________________________________ _____________________________________ Signed Date The patient, legal guardian, or health care surrogate, if any hereby authorizes Jason Manuel, D.P.M. to examine and treat if necessary _________________________________________________________ for Podiatric care. This consent may be withdrawn at any time. The patient, legal guardian, or health care surrogate, if any, has read and fully explained to him/her and fully understands the above Authorization for Treatment. No guarantee or assurance has been made to the patient, legal guardian, or health care surrogate, if any, concerning the results which may be obtained. _____________________________________ _____________________________________ Signed Date Patient Name: ___________________________________ Date of Birth: ______________________ Age: ________ Sex: ____________________________ Height: _________________________ Weight: ______________________ What is your main complaint today? _______________________________________________________________ __________________________________ Date of Injury / Accident / Onset of Symptoms: ____________________ Have you already been seen by a physician and / or Emergency Room for this? _____________________________ If so, name the physician and / or E.R. ______________________________________________________________ Is your problem related to an injury? _____________________ If so, was this an on-the-job injury? _____________ Have you had to stop working because of this injury? ______________________ What Date: __________________ POTENTIALLY RELATED HISTORY: If present, describe briefly, if not, then indicate with an “O” Mark. Answer each line. 1. Heart Problem: _______________________________________________________________________________ 2. High Blood Pressure: __________________________________________________________________________ 3. Breathing Problems: __________________________________________________________________________ 4. Diabetes: ___________________________________________________________________________________ 5. Stomach Problems: ___________________________________________________________________________ 6. Bowel Problems / Constipation / Diarrhea: ________________________________________________________ 7. Kidney or Bladder Problems (not including bladder infections): ___________________________________________ 8. Bleeding Tendency: ___________________________________________________________________________ 9. Jaundice / Hepatitis / Liver Disease: ______________________________________________________________ 10. Convulsions / Epilepsy (Falling Out): _____________________________________________________________ 11. Stroke: ____________________________________________________________________________________ 12. Headaches: ________________________________________________________________________________ 13. Visual Disturbances / Blurred or Double Vision: ____________________________________________________ 14. Dizziness / Vertigo: __________________________________________________________________________ 15. In the last two months, have you or any member of your family had flu? _______________________________ 16. Do you have a cold at the present time? _________________________________________________________ 17. Do you have a chronic cough, bronchitis or asthma? ________________________________________________ 18. Within the last 2 years, have you taken a drug Cortisone, Medrol, Decamethasone, Prednisone, Aristocort, Decadron, Steroids, Hydrocortisone, Prednisilone, or A.C.T.H.? __________________________________________ 19. In the last 2 weeks, have you taken any tranquilizers or nerve pills? ________ If so, what drugs? ____________ 20. Have you or any of your blood relatives ever had any reaction to local or general anesthesia? ______________ If yes, what? ________________________________________________________________________________ 21. Have you ever had arthritis or bone disease in your jaw, face or neck? _________________________________ MEDICATIONS: NONE: _____________________________? If yes. Please Answer Below. 1) _____________________ ___________________________________ _______________________________ 2) _____________________ ___________________________________ _______________________________ 3) _____________________ ___________________________________ _______________________________ 4) _____________________ ___________________________________ _______________________________ 5) _____________________ ___________________________________ _______________________________ ALLERGIES: NONE: _________? If yes, list skin, food, drug or any other causes and please describe symptoms. 1) ___________________________________________ 2) ___________________________________________ 3) ___________________________________________ 4) ___________________________________________ MISCELLANEOUS: (Please answer all questions) 1) Do you wear glasses / contacts? _________________________________________________________________ 2) Do you wear Dentures? - - - - - - - - - - - - - - - - - - - - Upper 3) Do you have a hearing aid? _____________________________________________________________________ 4) Do you smoke? _____________________________ If yes, how many packs per day? ______________________ 5) Do you drink Alcoholic Beverages? ______________ If yes, how often? _________________________________ 6) Are you on any special diet? ____________________________________________________________________ PREVIOUS / PRESENT PHYSICIAN: Please list the names of any physicians you may be seeing now or have seen in the past 1) _____________________ For _________________________________ Approx Date: ___________________ 2) _____________________ For _________________________________ Approx Date: ___________________ 3) _____________________ For _________________________________ Approx Date: ___________________ 4) _____________________ For _________________________________ Approx Date: ___________________ 5) _____________________ For _________________________________ Approx Date: ___________________ 1) _____________________ ______________________________ M.D. _______________________________ 2) _____________________ ______________________________ M.D. _______________________________ 3) _____________________ ______________________________ M.D. _______________________________ 4) _____________________ ______________________________ M.D. _______________________________ 13400 Sutton Park Drive South, Suite 1103 CONSENT FOR PURPOSES OF TREATMENT, PAYMENT I consent to the use or disclosure of my protected health information by Jason Manuel, DPM, P.A. or Life Remedies, P.A. for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of these practices. I understand that diagnosis or treatment of me by Jason Manuel, DPM, P.A. or Life Remedies, P.A. may be conditioned upon my consent as evidenced by my signature on this document. I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or health care operations of either practice named above. These practices are not required to agree to the restrictions that I may request. However, if Jason Manuel, DPM, P.A. or Life Remedies, P.A. agrees to a restriction that I request, the restriction is binding on that practice. I have the right to revoke this consent, in writing, at any time, except to the extent that Jason Manuel, DPM, P.A. or Life Remedies, P.A. has taken action in reliance on this consent. My “protected health information” means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information related to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. I understand I have a right to review the privacy policy of Jason Manuel, DPM, P.A. or Life Remedies, P.A. prior to signing this document. The Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the type of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Jason Manuel, DPM, P.A. or Life Remedies, P.A. The Notice of Privacy Practices for Jason Manuel, DPM, P.A. or Life Remedies, P.A. is also provided at 13400 Sutton Park Drive South, Suite 1103, Jacksonville, FL 32224. This Notice of Privacy Practices also describes my rights and the duties of Jason Manuel, DPM, P.A. or Life Remedies, P.A. with respect to my protected health information. Jason Manuel, DPM, P.A. or Life Remedies, P.A. reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment. _______________________________ ___________________________________________ Signature of Patient or Personal Representative ___________________________________________ Description of Personal Representative’s Authority

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