To Save time - Please Print this form,
fill it out and bring it with you on your first visit.

Dr. Neal Houslanger and Staff Welcome you to our office. We are pleased to have you with us. Please answer all questions to help us better understand your background. If you need help please do not hesitate to ask.

All information is strictly confidential. PLEASE CIRCLE ALL ANSWERS THAT APPLY.

NAME________________________________________ DATE OF BIRTH_______________ Age________

HOME ADDRESS_____________________________ City_____________________ Zip Code__________

HOME TELEPHONE________________ WORK PHONE_____________________ SS#_______________

EMPLOYED BY______________________________ OCCUPATION______________________________

MARITAL STATUS M S W D NAME OF (SPOUSE) OR (PARENT)________________________

WHOM MAY WE THANK FOR REFERRING YOU TO OUR OFFICE? ______________________________

ARE YOU COVERED BY MEDICAL INSURANCE? YES NO

IF YES, NAME OF INSURANCE COMPANY? _________________________________________________

IDENTIFICATION #______________________________GROUP # ____________________________________

NAME ON POLICY_____________________ INDIVIDUAL'S RELATIONSHIP TO YOU________________

PLEASE DESCRIBE CURRENT FOOT PROBLEM AND WHEN IT STARTED________________________

ARE YOU IN GOOD HEALTH? YES NO

ARE YOU NOW OR HAVE YOU BEEN UNDER A PHYSICIAN'S CARE DURING THE PAST 2 YEARS? YES NO WHO IS YOUR CURRENT FAMILY DOCTOR____________________________________

WHAT MEDICATIONS ARE YOU CURRENTLY TAKING________________________________________

PLEASE LIST ANY MEDICATIONS YOU ARE ALLERGIC TO____________________________________

Circle All you may be ALLERGIC TO: NOVOCAINE PENICILLIN ADHESIVE TAPE BETADINE

PLEASE CIRCLE ANY OF THE FOLLOWING MEDICAL CONDITIONS YOU HAVE OR HAD:

ABNORMAL HEART AIDS ANEMIA (low blood count) ARTHRITIS ASTHMA BLEEDING ABNORMALITIES CIRCULATION PROBLEMS CONVULSIONS DIABETES EMOTIONAL EMPHYSEMA EPILEPSY HEPATITIS HIGH BLOOD PRESSURE JAUNDICE (yellowing of skin) KIDNEY LIVER LOWER BACK LUNGS PHLEBITIS PNEUMONIA RHEUMATIC FEVER SCIATICA SHOCK STROKE THYROID TUBERCULOSIS ULCERS VENERIAL DISEASE VARICOSE VEINS

PREVIOUS FOOT PROBLEMS Please List___________________________________________________

Please list any other illnesses______________________________________________________________

Please List All Past Surgeries and Hospitalizations with Approximate Dates__________________________

______________________________________________________________________________________

How much do you Smoke _________Packs per Day. How much do you Drink_____________________

I hereby give my permission to Dr. Neal Houslanger to administer treatment, and to perform such diagnostic procedures as may be deemed necessary in the diagnosis and/or treatment of my foot condition.

DATE______________ SIGNATURE________________________________________________________