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Last Name First Name MI
__ American Indian/Alaskan Native __ Asian __ Black/African American __ Hawaiian/Pacific Islander __ White __Other Shoe Type: __ Dress __ Work Boot __ Steel/Ceramic Toed PATIENT CONTACT INFORMATION
Primary Care Physician Name:
___ Result of Auto Accident ___ Result of Injury while at Work Workman's Comp Claim #: ___________________________ How did you hear about our practice: ___Google ____Zoc Doc ____ Phone Book ___ Insurance Company ___ Sign/Location ___ Physician Referral ____ Friend/Family Name:_______________ Other:__________________________ FOOT & ANKLE CLINICS OF AMERICA
Primary Insurance Information
Secondary Insurance Information
Medical history
:__ Diabetes___# of years __ Renal Disease__ Dialysis __ Heart Disease __ Stroke __ Heart attack __ HIV __ Dementia
__ Hypertension __ High Cholesterol __ Sickle Cell __ Varicose Veins __ Hepatitis __ Neuropathy __ Arthritis __ Gout __ Blood Clots Please specify any other medical conditions: Allergies: __ None __ Penicillin __ Sulfa __ Codeine __ Iodine __ Latex __ Local Anesthetics __ NSAIDS __ Aspirin __ Food
Reaction type: ____________________________________________ Medications and Vitamins Please List:
Are you currently taking: __ Coumadin __ Plavix __ Pletal __ Lovenox __ Aspirin Past Surgeries: __ None __ Appendectomy __ Tonsilectomy __ Hysterectomy __ Stents __ Bypass Procedures __ Arthroscopy
__ Knee replacement __ Hip Replacement __ Back Surgery __ AV fistula __ Transplants __ Varicose Veins __Fracture Repair Other: _________________________________________________ Complications: __ Problems with anesthesia __ Blood Clots Family History: __Heart Disease __ Stroke __ Diabetes __ Cancer __Rhematoid Arthritis
Social History: Do you use the following for ambulation: ___ Walker ___ Cane ___ Wheel Chair ___ Brace ___ Prosthetic
Tobacco: __ None __ Current __ History of Use # of Packs per day:______ # of years: ______ When did you quit: _______ Alcohol: __ None __Current __History of abuse # Drinks per week: _____ Recreational Drug Use: __ None __ Current __ History of Use When did you quit:_______ What type:_____________
Exercise Activities: __ Walking __ Running __ Bicycling __ Weight lifting __ Elliptical __ Swimming __ Yoga/Pilates Other: ________________________ # times per week: ______________________ Living Situation: ___ Alone ___ Nursing Home ___ Caretaker ___ Family Other:____________ I hereby give my permission to the physician of Foot & Ankle Clinics of America to administer any non-surgical treatment that maybe necessary to treat my foot condition. I understand that I am financially responsible for all charges (whether or not covered by the insurance company). I understand it is my responsibility to be knowledgeable about my insurance plan and it's coverage. I understand that if I receive a check from my insurance company for services provided by Foot & Ankle Clinics of America, I am responsible for paying Foot & Ankle Clinics of America immediately. Co-Payments must be paid at the time of service.
Signature: _________________________________________________________________________ Date: _________________________ I authorize the release of any medical information necessary to process my insurance claim. I authorize payment of Medical Benefits to Foot & Ankle Clinics of America, LLC (must sign prior to treatment). We need copies of all Insurance cards/Driver's License/State ID
Signature: _________________________________________________________________________ Date: _________________________


The Charismatic Movement 35 Doctrinal Issues TABLE OF CONTENTS 1. Have you received the Holy Spirit? 2. How do you know that the Holy Spirit dwells within you? 3. Did your salvation package include the gift of the Holy Spirit? 4. Should believers look for a second blessing? 5. What is the evidence or proof of having received t

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Herb-Drug Interactions „ Herbs with higher risk of adverse reactions John K. Chen, Ph.D., Pharm., O.M.D., L.Ac. Evergreen Herbs and Medical Supplies, LLC17431 East Gale Ave. City of Industry, CA 91748Copyright 2004. Chen and Chen. Chinese Medical Herbology and Pharmacology. Page: 25-30Copyright 2004. Chen and Chen. Chinese Medical Herbology and Pharmacology. Page: 25-30C

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