5605 W. Eugie Ave., Suite 102
Glendale, AZ 85304
602-547-2111 Fax: 602-547-0473
PATIENT INFORMATION FORM
THUNDERBIRD FOOTCARE
DATE: ____/_____/_____
PATIENT NAME: _________________________________________________ DATE OF BIRTH: ____/____/____ SEX: M F
FIRST
MI
LAST
HOME ADDRESS: __________________________________________CITY/STATE: ____________________ ZIP: _____________
RACE/ETHNICITY (CIRCLE ONE) CAUCASIAN/WHITE, BLACK/AFRICAN AMERICAN , ASIAN, NATIVE AMERICAN,
LATIN/HISPANIC, OTHER, PREFER NOT TO ANSWER
MAY WE LEAVE A MESSAGE ?
HOME PHONE #:
CIRCLE WHICH ONE IS YOUR PREFERENCE
____________________________________________
YES NO
E-MAIL: ____________________________________________________________
YES NO
CELL PHONE#:
WORK PHONE #:
____________________________________________
____________________________________________
YES NO
YES NO
EMERGENCY CONTACT: ______________________________ RELATIONSHIP: _____________PHONE #: ___________________
PRIMARY CARE DOCTOR: ________________________________________ PHONE: _______________FAX:__________________
REFERRING DOCTOR:___________________________________ PHONE: ________________________FAX:__________________
PHARMACY: _____________________________ LOCATION: __________________________ PHONE #: ___________________
WHO WOULD YOU ALLOW US TO SHARE YOUR MEDICAL INFORMATION, IF NECESSARY
NAMES:______________________________________________RELATIONSHIP_____________________________________________
NAMES:______________________________________________RELATIONSHIP_____________________________________________
DO YOU HAVE A LEGAL GUARDIAN OR HEALTHCARE POWER OF ATTORNEY?
YES NO
IF YES, NAME: _______________________________ RELATIONSHIP: ______________PHONE:___________________________
IF INJURY WAS RELATED TO AUTO/WORK ACCIDENT/ETC., SEE FRONT OFFICE PERSONNEL BEFORE COMPLETING
INSURANCE INFORMATION
PRIMARY INSURANCE COMPANY NAME: ______________________________________________________________________
INSURED NAME: _____________________________________________INSURED BIRTHDATE ________________________
EMPLOYER:________________________________________________
SECONDARY INSURANCE COMPANY NAME: ______________________________________________________________________
INSURED NAME: ____________________________________________INSURED BIRTHDATE __________________________
EMPLOYER _________________________________________________
Revised July 2016
PATIENT NAME: _______________________________________________________
LAST
MARITAL STATUS:  SINGLE
FIRST
 MARRIED
MI
 PARTNERED
 SEPARATED
 DIVORCED
USE OF ALCOHOL:  NEVER  NO LONGER USE  HISTORY OF ALCOHOL ABUSE
 CURRENT USE - TYPE __________________  RARE  OCCASIONAL  MODERATE
 WIDOWED
 DAILY
USE OF TOBACCO:  NEVER  QUIT – HOW LONG AGO? _________  SMOKE ____ PACKS/DAY FOR ____ YEARS
USE OF RECREATIONAL DRUGS:  NEVER
 QUIT – HOW LONG AGO? _________ TYPE _____________________
 CURRENT USE - TYPE _______________  RARE
EMPLOYER: ___________________________________________
HOW MUCH ARE YOU ON YOUR FEET AT WORK?  10%
 OCCASIONAL
 MODERATE
 DAILY
OCCUPATION: _______________________________________
 25%
 50%
 75%
 100%
DO OTHERS DEPEND UPON YOU FOR THEIR CARE?  CHILDREN–AGE(S) ________________________________________
 ELDERLY OR DISABLED FAMILY MEMBER ___________________________________________________  SPOUSE ________
EXERCISE:  NEVER  RARE
 OCCASIONAL
 WEEKLY
 SEVERAL TIMES A WEEK
 DAILY
TYPES OF EXERCISE: _____________________________________________________________________________________
DO YOU HAVE A FAMILY HISTORY OF:
 DIABETES: TYPE 1 OR TYPE 2  CANCER  HEART DISEASE
 HIGH BLOOD PRESSURE
 STROKE
 CORONARY ARTERY DISEASE
 THYROID DISEASE
 RHEUMATOID ARTHRITIS
 OTHER _____________________________________________________
PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING/ PLEASE GIVE LIST TO FRONT OFFICE
(INCLUDE PRESCRIPTIONS, OVER-THE-COUNTER MEDS AND HERBAL SUPPLEMENTS, VITAMINS ETC.)
DOSE
HOW OFTEN DO YOU TAKE?
NAME
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
ALLERGIES: PLEASE LIST __________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
PLEASE LIST ALL PRIOR SURGERIES & DATE
________________________________________________________
________________________________________________________
________________________________________________________
______________________________________________________
PLEASE LIST ALL HOSPITALIZATIONS & DATE
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
 CURRENT FLU SHOT DATE_____________________________  PNEUMONIA SHOT DATE___________________________
Revised July 2016
PATIENT NAME: __________________________________________________
LAST
FIRST
YOUR MEDICAL HISTORY
HEIGHT: ______________________________________
HAVE YOU EVER HAD ANY OF THE FOLLOWING?
ACID REFLUX
ANEMIA
ARTHRITIS
ASTHMA
BACK TROUBLE
BLADDER INFECTIONS
ABNORMAL BLEEDING
BLOOD CLOTS
BLOOD TRANSFUSION
BRONCHITIS/EMPHYSEMA
CANCER
DIABETES: TYPE 1 OR
TYPE 2 (CIRCLE)
YEAR OF DIAGNOSIS
CURRENT DIABETIC
HGA1C%
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
MI
WEIGHT___________________________________
FIBROMYALGIA
GOUT
HEART ATTACK
HEART DISEASE/FAILURE
HEPATITIS A B C
HIV+/AIDS
HIGH BLOOD PRESSURE
KIDNEY DISEASE
LIVER DISEASE
LOW BLOOD PRESSURE
MIGRAINE HEADACHES
MITRAL VALVE PROLAPSE
DR. FOR DIABETES CARE
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
NEUROPATHY
OPEN SORES
PNEUMONIA
POLIO
RHEUMATIC FEVER
SICKLE CELL DISEASE
SKIN DISORDER
SLEEP APNEA
STOMACH ULCERS
STROKE
THYROID DISEASE
TUBERCULOSIS
FAX#
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
CURRENT PROBLEM
WHAT SPECIFIC PROBLEM BRINGS YOU TO OUR OFFICE TODAY? __________________________________________________
WHERE IS THE PAIN/PROBLEM LOCATED? PLEASE MARK ON THE PICTURES BELOW.
LEFT FOOT
TOP OF FOOT
INSIDE OF FOOT
Revised July 2016
RIGHT FOOT
BOTTOM OF FOOT
OUTSIDE OF FOOT
BOTTOM OF FOOT
TOP OF FOOT
OUTSIDE OF FOOT
INSIDE OF FOOT
PATIENT NAME: ______________________________________________________________________
LAST
FIRST
MI
WHAT IS YOUR SHOE SIZE? _______________________________
WHAT TYPE OF SHOES DO YOU COMMONLY WEAR? CIRCLE ONE: SNEAKERS/ DRESS / SANDALS/ FLIP FLOPS
FLAT SHOES / SLIPPERS / HEELS / WORKS BOOTS OR OTHER______________________________________________________
HAVE YOU SEEN ANOTHER PODIATRIST FOR THIS CURRENT PROBLEM
 YES
 NO
HOW LONG AGO DID THIS PROBLEM FIRST START? _______________________ DAYS/ WEEKS/ MONTHS/ YEARS
DID YOUR FOOT PAIN OR PROBLEM:  BEGIN ALL OF A SUDDEN  GRADUALLY OVER TIME
 OTHER
PLEASE EXPLAIN ____________________________________________________________________________________________
HOW WOULD YOU DESCRIBE YOUR PAIN?  NO PAIN  SHARP  DULL  ACHING  BURNING
 RADIATING  ITCHING  STABBING  OTHER ________________________________________________
HOW WOULD YOU RATE YOUR PAIN ON A SCALE FROM 0 TO 10? (PLEASE CIRCLE)
(NO PAIN) 0
1
2
3
4
5
6
7
8
9
10 (WORST PAIN POSSIBLE)
SINCE THE TIME YOUR PAIN OR PROBLEM BEGAN, HAS IT:  STAYED THE SAME  BECAME WORSE  IMPROVED
WHAT MAKES YOUR PAIN OR PROBLEM FEEL WORSE?  WALKING  STANDING  DAILY ACTIVITIES
 RESTING  DRESS SHOES  HIGH HEELS  FLAT SHOES  ANY CLOSED TOE SHOE
 RUNNING  OTHER ________________________________________________________________________________
WHAT MAKES YOUR PAIN OR PROBLEM
FEEL BETTER? _________________________________________________________
WHAT TREATMENTS HAVE YOU HAD FOR THIS PROBLEM? ______________________________________________________
HOW HAS THIS PROBLEM AFFECTED YOUR LIFESTYLE OR ABILITY TO WORK? ____________________________________
WAS THIS PROBLEM CAUSED BY AN INJURY?  YES (DESCRIBE) ______________________________________
IF YES, WAS IT A WORK-RELATED INJURY?  YES
 NO
 NO
IF YES, PLEASE SEE FRONT OFFICE STAFF
TO THE BEST OF MY KNOWLEDGE, I HAVE ANSWERED THE QUESTIONS ON THIS FORM ACCURATELY. I
UNDERSTAND THAT PROVIDING INCORRECT INFORMATION CAN BE DANGEROUS TO MY HEALTH. I UNDERSTAND
THAT IT IS MY RESPONSIBILITY TO INFORM THE DOCTOR AND OFFICE STAFF OF ANY CHANGES IN MY MEDICAL
STATUS.
____________________________________________________________________
PRINT NAME OF PATIENT, PARENT OR GUARDIAN
____________________________________________________________________
IF OTHER THAN PATIENT, RELATIONSHIP TO PATIENT
SIGNATURE_________________________________________DATE_________________________________________
Revised July 2016