Download Report

Kurt E. Kinghorn, DPM, AACFAS
222 N 2nd St Suite 301
Boise, Idaho 83702
208-344-3324
Initial Visit Date: ____________________
Time: ____________ (AM) (PM)
PATIENT INFORMATION:
Last Name: __________________________ First: ____________________ MI: _____
What name do you prefer? _____________________________________________
Mailing Address: ____________________________________________________
City: _____________________ State: __________________ Zip: _____________
Email: ______________________________________
TELEPHONE NUMBERS:
PRIMARY CARE PHYSICIAN:
Home: (_____) _______________
Doctor: ___________________________
Work: (_____) _______________
Phone: (_____) _____________________
Cell: (______) _______________
Address: __________________________
Emergency Contact: _____________
City: _______ State: _____ Zip: _______
Emergency Phone: (____) __________
PATIENT IDENTIFICATION:
SPOUSE IDENTIFICATION:
Social Security #: ____-_____-_____
Name: _________________________
Birth Date: ___________ Age: _____
Address: _______________________
Gender: Male _____ Female _______
City: _______ State: ____ Zip: ______
Marital Status: S M W D Sep (Circle One)
SSN#: ____-____-____ DOB: ______
Pharmacy: __________Phone: ________
Employer: _________ Phone: _______
PATIENT EMPLOYMENT:
Employer: ________________ Occupation: _____________ Phone #: __________
Employer Address: ________________ City: _________ State: _____ Zip: ______
Is your problem due to an accident? Y N What caused it? ____________________
Kurt E. Kinghorn, DPM, AACFAS
222 N 2nd St Suite 301
Boise, Idaho 83702
208-344-3324
INSURANCE INFORMATION
PRIMARY INSURANCE:
INSURANCE NAME:___________________________________________________
ADDRESS:____________________________________________________________
CITY: __________________ STATE: ________________ ZIP: __________________
POLICY HOLDER: ___________________________ DOB # ___________________
POLICY #: _____________________________ GROUP #: _____________________
PHONE #: (____) _____________ COPAY: ________
SECONDARY INSURANCE:
INSURANCE NAME:___________________________________________________
ADDRESS: ___________________________________________________________
CITY: ____________________ STATE: ________________ ZIP: ________________
POLICY HOLDER: ___________________________ DOB # ___________________
POLICY #: _____________________________ GROUP #: _____________________
PHONE #: (____) ______________ COPAY: _______
DRIVERS LICENSE #: ______________ STATE: _________ EXP DATE: ________
Dr. Kinghorn will bill all charges to my insurance carrier as a courtesy; however, I
understand that I am ultimately responsible for payment of services regardless of insurance
coverage. If my account is referred to a collection agency, I understand that I am responsible
for collection fees and any legal fees that are incurred by the action.
PATIENT / GUARDIAN SIGNATURE
DATE
Kurt E. Kinghorn, DPM, AACFAS
222 N 2nd St Suite 301
Boise, Idaho 83702
208-344-3324
PATIENT HEALTH HISTORY
Patient Height: _______ Patient Weight: ________
Patient Shoe Size: __________
Please indicate if you(s) or your family(f) have or have had any of the following:
S
General Medical History
F
Diabetes
Arthritis
Circulation Problems
Gout
Anemia
Asthma
Stomach Ulcers
Hardening of Arteries
Infection Prone
Bleed Easily
Slow Healer
Heart Trouble
Kidney Trouble
Liver Trouble
Fainting Spells
High Blood Pressure
Polio
Rheumatic Fever
Tuberculosis
Cancer
Epilepsy
Gangrene
Hepatitis
HIV Positive
S
Foot & Leg Conditions
F
Bunions
Bone Fracture
Bow Legs
Burning
Arch Pain
Foot Cramps
Unequal Leg Lengths
Knee Pain
Heel Pain
Knocked Knees
Sprains
Low Back Pain
Varicose Veins
Nerve Injury
Stiffness
Coldness
Numbness
Pigeon Toes
Toes Outward
Flat Feet
High Arches
Hammer Toes
Leg Cramps
S
Foot Skin Problems
F
Fungus
Growths
Hard Corns
Soft Corns
Dryness
Calluses
Moist Skin
Toe Nail Problems
Fungus
Thick
Curved
Ingrown
Brittle
Deformed
Discolored
Shoe Wear Problems
Tip
Heel
Upper
Soles
What treatment (including surgeries) have you had for these problems?
_____________________________________________________________
List any medications you are taking and their dosage___________________
_____________________________________________________________
Drug Allergies:_________________________________________________
Do you Smoke? ______ (#of packs per day) ______ Quit __________
Do you drink alcoholic beverages? _______ How much ________
Kurt E. Kinghorn, DPM, AACFAS
222 N 2nd St Suite 301
Boise, Idaho 83702
208-344-3324
Patient Name: _______________ Date of Birth: _____________________
Chief Complaint
Reason for today’s Visit? ________________________________________
Current problem is the result of a (n): Check all that apply
Car Accident Work Accident
Accident
Other__________________
Date of onset _______________________
Where is the pain located? (Shade area of foot on diagram)
Overall, is the problem getting better, worse or no change? ______________
What previous treatment (including surgeries) have you had for this problem?
Did the treatment help?
What has helped the pain? (I.e. aspirin type products, decrease activity, shoe wear
change)_______________________________________________
What makes the symptoms worse: (i.e. activity)
Which one of the following describes the intensity of the pain?
Nonexistent
Mild, occasional
Moderate, daily
Severe, almost always present
Do you have difficulty walking on:
Level ground ____Uneven ground_____ Stairs_____ Hills _____
Ladders _____
Kurt E. Kinghorn, DPM, AACFAS
222 N 2nd St Suite 301
Boise, Idaho 83702
208-344-3324
FINANCIAL AGREEMENT
 This office will file insurance claims for all insurance companies. Please provide a copy
of your insurance card. You are responsible for knowing the provisions of your policy.
 If you do not have insurance coverage or cannot provide proof of insurance, we will give
a 20% discount if payment is made in full at time of visit. If it cannot be paid at time of
visit we will require 4 equal payments.
 Regardless of insurance coverage, you remain responsible for payment of your account.
 Patients are responsible for their deductible or 20% of total charges at the time of your
visit.
 A $25.00 fee will be charged for appointments that are canceled without a 24 hour notice.
 A finance charge of 1.5% per month may be added to accounts more than 60 days old.
 A $15.00 fee will be charged on all returned checks regardless of the reason.
Signature:__________________________________ Date:_______________________
ACKNOWLEDGEMENT OF RECEIPT
OF
NOTICE OF PRIVACY PRACTICES
I acknowledge that I was provided a copy of the Notice of Privacy Practices and I have
read (or had the opportunity to read if I so chose) and understood the Notice.
Patient Name (please print)
Parent or Authorized Representative (if applicable)
Signature
Date