Peter M. Wilusz, D.P.M.
Town Center Foot and Ankle
TODAY’S DATE:______
PERSONAL INFORMATION
LAST NAME:______FIRST: ______MI:_____
BIRTHDATE: ______SSN: ______MARITAL STATUS (circle): M S D W
SEX (circle): M F PHONE NUMBER: H:______C:______W:______
ADDRESS: ______
(street) (city) (state) (zipcode)
EMAIL: ______ARE YOU A DIABETIC? ______IF SO, TYPE? ______
EMERGENCY CONTACT: ______
(name) (relationship) (phone)
HOW WERE YOU REFERRED TO OUR OFFICE? ______
PRIMARY CARE PHYSICIAN: ______DATE OF LAST VISIT:______
(name) (phone)
PHARMACY: ______
(name) (location) (number)
DEMOGRAPHICS
ETHNICITY (circle one): HISPANIC/LATINO or NOT HISPANIC/LATINO or DECLINED
LANGUAGE SPOKEN AT HOME: ______
RACE (circle one): WHITE or BLACK/AFRICAN AMERICAN or ASIAN or AMERICAN INDIAN
NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER or ALASKA NATIVE or DECLINED
INSURANCE INFORMATION
EMPLOYER: ______OCCUPATION: ______
PRIMARY INSURANCE: ______SECONDARY INSURANCE:______
SUBSCRIBER’S NAME: ______SUBSCRIBER’S NAME: ______
SUBSCRIBER’S BIRTHDATE: ______SUBSCRIBER’S BIRTHDATE:______
RELATIONSHIP TO SUBSCRIBER: ______RELATIONSHIP TO SUBSCRIBER: ______
MEMBER ID: ______MEMBER ID:______
GROUP #: ______GROUP #:______
SPECIALIST OFFICE COPAY: ______SPECIALIST OFFICE COPAY:______
The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Peter M. Wilusz, D.P. M., or insurance company to release any information required to process my claims.
Patient/Guardian Signature ______Date: ______
I hereby consent and give permission to the doctor (and the doctor’s assistants or designated replacement) to administer and perform such procedures on me as the doctor deems necessary.
Patient/Guardian Signature ______Date: ______
GENERAL HEALTH & SOCIAL HISTORY
CURRENT WEIGHT: ______HEIGHT: ______SHOE SIZE: ______
PLEASE CIRCLE ANY OF THE FOLLOWING YOU HAVE OR HAVE HAD IN THE PAST:
ANGINA
ANEMIA
ARTIFICIAL IMPLANT
BLADDER PROBLEMS
CANCER HISTORY
DIABETES TYPE 1
EMPHYSEMA
FAINTING
GOUT
HEART ATTACK
HIATAL HERNIA
HYPERTENSION
LEG PAIN WITH ACTIVITY
NIGHT CRAMPS
PSYCHIATRIC CONDITIONS
SHORTNESS OF BREATH
STROKE
THYROID DISEASE
VALVULAR HEART DISEASE
WEIGHT GAIN
LUNG DISEASE
ARRYTHMIA
ASTHMA
BOWEL DISORDER
CONGENTIAL NERVE DISORDER
DIABETES TYPE 2
EPILEPSY
FOOT/LEG CRAMPS
HEADACHES
HEART DISEASE
HYPERTENSION
HYPOTENSION
LIVER DISEASE
POOR CIRCULATION
RADIATION
SINUS PROBLEMS
SWELLING
TUBERCULOSIS
VARICOSE VEINS
WEIGHT LOSS
ACID REFLUX
ARTHRITIS (type) ______
BACK PROBLEMS
BRONCHITIS
COPD
DRY MOUTH/EYES
EYE PROBLEMS
GI/RECTAL BLEEDING
HEARING PROBLEMS
HEMOPHILIA
HYPERLIPIDEMIA
KIDNEY PROBLEMS
NEUROPATHY
PROSTATE PROBLEMS
RASH
STOMACH PROBLEMS
SWOLLEN GLANDS
ULCERS
VENERAL DISEASE
HEPATITIS (circle): YES NO HIV STATUS (circle): POSITIVE NEGATIVE UNKNOWN
PAST INJURIES & DATES: ______
PAST SURGERIES & DATES: ______
ANY ADVERSE REACTIONS TO ANESTHESIA? ______IF SO, WHAT HAPPENED? ______
MEDICATION ALLERGIES: REACTION: DEGREE OF SEVERITY
(mild, moderate,severe):
______
______
______
______
______
______
OTHER ALLERGIES: ______
CURRENT MEDICATIONS: DOSAGE: (how many) STRENGTH: (mg) FREQUENCY: (times per day)
______
______
______
______
______
______
______
______
______
FAMILY MEDICAL HISTORY/DISEASES:
MOTHER: ______FATHER: ______
GRANDMOTHER: ______GRANDMOTHER: ______
GRANDFATHER: ______GRANDFATHER: ______
DO YOU EXERCISE? YES NO IF SO, HOW MANY MINUTES PER SESSION? ______
TYPE OF EXERCISE: ______FREQUENCY: DAY MONTH WEEK
STRESS LEVEL: LOW MODERATE HIGH
PAIN (circle): BACK ANKLE GENERALIZED NECK HIP KNEE SHOULDER ELBOW WRIST
SMOKING STATUS (circle): CURRENT EVERYDAY SMOKER CURRENT SOME DAY SMOKER
FORMER SMOKER NEVER SMOKER
ALCOHOL USAGE (circle): YES NO TYPE: BEER WINE LIQUOR
AMOUNT (# of drinks) ______PER DAY WEEK MONTH YEAR
DRUG USAGE (circle): YES NO IF YES, DRUG OF CHOICE: ______