Patient Information Form Online

Please complete all the information below. This form is composed of the Patient Information form and the Medical Information form. Once you are satisfied with your entries click on the submit button at the bottom of the page. If you need help or have any question please call our office at 954-748-9444 .

Patient Information
Last First MI
Name: 
Birth Date: 
/ /
Age: 
Sex: 
Male   Female  
Email Address: 
Current Address:    Apt. 
City: 
State:  Zip: 
Home Phone
  
Work Phone
Area Code Area Code
( )   –       ( )   – 
 
Permanent Address: 
City: 
State:  Zip: 
Home Phone
  
Social Security Number
Area Code
( )   –        –   – 
Drivers License Number: 
Marital Status:   Single   Married   Divorced   Widowed  
Name of Spouse: 
 
 
Employment Information
Employer Occupation
Business Address 
City: 
State:  Zip: 
Business Phone
Area Code
( )   – 
 
Insurance Information
Do you have medical insurance?   Yes    No
Primary Insurance Carrier Information
Insurance Company 
Policy Number 
Group Number 
Address 
City: 
State:  Zip: 
Name of Insured: 
Relationship to  Insured: 
Insured Date of Birth
  
Insured Social Security No.
/ /         –   – 
 
Secondary Insurance Carrier Information
Insurance Company 
Policy Number 
Group Number 
Address 
City: 
State:  Zip: 
Name of Insured: 
Relationship to  Insured: 
Insured Date of Birth
  
Insured Social Security No.
/ /         –   – 
 
Person Responsible for Account: 
Address 
City: 
State:  Zip: 
 
Medical History
Family Physician 
Date of last Medical 
Exam: 
Physician  Address: 
City: 
State:  Zip: 

Physician Phone:
Area Code
( )   – 
 
What medications are your presently taking or use on occasion (if any), including prescription medications, over-the-counter medications and vitamins?

 
Are you allergic to any medications you know of?

 
Are you being treated or have you been treated in the past for any of the following?
 
     High blood pressure (hypertension)   Yes    No
     Low blood pressure   Yes    No
     Diabetes   Yes    No
     Poor circulation   Yes    No
     Phlebitis   Yes    No
        Which leg(s)
     Glaucoma   Yes    No
     Heart Murmurs   Yes    No
     Mitral valve prolapse   Yes    No
     Angina   Yes    No
     Other heart problems   Yes    No
        explain
     Emphysema   Yes    No
     Tuberculosis   Yes    No
     Asthma   Yes    No
     Other respiratory problems   Yes    No
        explain
     Ulcers   Yes    No
     Hiatal Hernia   Yes    No
     Other G.I. problems   Yes    No
        explain
     Arthritis   Yes    No
     Gout   Yes    No
     Stroke   Yes    No
     Epilepsy   Yes    No
     Multiple sclerosis   Yes    No
     Muscular dystrophy   Yes    No
     Neuropathy   Yes    No
     Other neuromuscular problems   Yes    No
        explain
     Psoriasis   Yes    No
     Cancer   Yes    No
        Cancer type?
 
Please describe any operations or hospitalizations you have had and list the dates:

 
What problem(s) are you having with your feet or legs today?

 
Other foot or leg problems you are concerned about?

Height:  Weight:  Shoe Size:  Shoe Type: 
    

  return to top

  

Home | About the Doctor | Our Office | Our Location | Our Services
Additional Information | New Patient Info
Foot Care Products | Contact Us

©2006 Dr. Sheldon Ross. All rights reserved.
Web site design and maintenance by Physician Webpages