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Address:
10550 Quivira Road, Suite 360 Overland Park, KS 66215 |
Appointments:
(913) 894-4040 |
General Inquiries:
(913) 894-4040
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New Patient Form
New Patient Form
ddmg
2020-06-24T02:45:41+00:00
Prefer using paper instead of digital?
Click the buttons below to download and print of your new patient paperwork, and complete by hand prior to your visit.
New Patient Packet
Authorization for Disclosure of Protected Health Info
Submit Paperwork Digitally Online
Step
1
of
5
20%
PATIENT INFO
Name
*
First
Last
Date of Birth
*
MM slash DD slash YYYY
Height
*
Please Select...
4'0"
4'1"
4'2"
4'3"
4'4"
4'5"
4'6"
4'7"
4'8"
4'9"
4'10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
6'9"
6'10"
6'11"
7'0"
Weight
*
Shoe Size
*
Please Select...
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Gender
*
Male
Female
Unknown
Marital Status
*
Single
Married
Widow
Divorce
Primary Language
*
Please select one...
English
Spanish
French
German
Italian
Mandarin
Other
Race
*
Please select one...
American Indian
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Ethnicity
*
Please select one...
Hispanic or Latino
Non-Hispanic or Latino
Flu Shot?
*
Please select one...
Yes
No
Pneumonia Vaccine?
*
Please select one...
Yes
No
PATIENT CONTACT
Home Phone
Cell Phone
*
Email
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
EMPLOYMENT
Employer
*
Occupation
Employer Phone
Employer Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
PRIMARY PHYSICIAN
Do you have a Primary Care Physician?
*
Yes
No
Name of Primary Care Physician
*
First
Last
Have you recently seen your Primary Care Physician?
*
Yes
No
Date Last Seen
*
MM slash DD slash YYYY
Preferred Pharmacy Name
*
Preferred Pharmacy Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
GUARANTOR INFO
Name
*
First
Last
Relationship
*
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employer
Occupation
Employer Phone
Employer Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Does this person also serve as your emergency contact?
*
Yes
No
Emergency Contact Name
*
First
Last
Home Phone
Cell Phone
*
Relationship
*
INSURANCE INFO
Primary Insurance Company Name
Name of the Insured
First
Last
Date of Birth
MM slash DD slash YYYY
Relationship to Patient
ID #
Group #
Secondary Insurance?
Yes
No
Secondary Insurance Company Name
Name of the Insured
First
Last
Date of Birth
MM slash DD slash YYYY
Relationship to Patient
ID #
Group #
Will your claims be filed to workers compensation?
*
Yes
No
Worker's Comp Insurance Company Name
*
Contact Name
*
First
Last
Address to Send Claims
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
How did you become aware of our service?
Insurance Company
YellowPages
Website
Referral
Other
Referred By:
First
Last
HEALTH HISTORY
Past Surgical History and Hospitalizations
*
Please select one...
Yes
No
Please list all procedures (with dates and reasons)
*
Are you or have you ever been a smoker?
*
Please select one...
Current
Former
Never
Do you live with a smoker?
*
Please select one...
Yes
No
Do you drink alcohol?
*
Please select one...
Yes
No
Number of drinks per week?
*
Please select one...
1-2
3-5
5-10
10+
Do you drink Caffeine?
*
Please select one...
Yes
No
Do you take recreational drugs?
*
Please select one...
Yes
No
Currently Employeed?
*
Please select one...
Yes
No
Do you have children?
*
Please select one...
Yes
No
Number of children?
*
Please select one...
1
2
3
4
5
6
7
8
9
10
Are you Pregnant?
*
Please select one...
Yes
No
Medical History
*
Please CHECK any current or past conditions
Alcoholism
Anemia
Anorexia
Appendicitis
Arthritis
Asthma
Bleeding Disorder
Bronchitis
Cancer
Cataracts
Chemical Dependency
Chicken Pox
CHF
Coronary Disease
COPD
Dementia
Diabetes
Emphysema
Epilepsy
Gout
Heart Attack
Heart Disease
Hepatitis
Hernia
High Blood Pressure
High Cholesterol
HIV/AIDS
Kidney Disease
Liver Disease
Measles
Migraines
Miscarriage
Mononucleosis
Multiple Sclerosis
Mumps
Pacemaker
Pneumonia
Polio
Prostate Problem
Psychiatric Care
Rheumatic Fever
Scarlet Fever
Seizures
Stroke
Suicide Attempt
Thyroid Problems
Tonsillitis
Tuberculosis
Typhoid Fever
Ulcers
NONE.
What is your current A1C?
*
Family History
*
Please CHECK if any family member current or past conditions
(Pick condition and then complete family member, pick another condition and then complete family member, etc.)
Arthritis
Asthma
Cancer
Chemical Dependency
COPD
Diabetes
Glaucoma
Gout
Heart Attack
Heart Disease
High Blood Pressure
Kidney Disease
Mental Illness
Stroke
Tuberculosis
NONE.
List Who
*
Mother
Father
Sibling
Child
Grandmother
Grandfather
List Who
*
Mother
Father
Sibling
Child
Grandmother
Grandfather
List Who
*
Mother
Father
Sibling
Child
Grandmother
Grandfather
List Who
*
Mother
Father
Sibling
Child
Grandmother
Grandfather
List Who
*
Mother
Father
Sibling
Child
Grandmother
Grandfather
List Who
*
Mother
Father
Sibling
Child
Grandmother
Grandfather
List Who
*
Mother
Father
Sibling
Child
Grandmother
Grandfather
List Who
*
Mother
Father
Sibling
Child
Grandmother
Grandfather
List Who
*
Mother
Father
Sibling
Child
Grandmother
Grandfather
List Who
*
Mother
Father
Sibling
Child
Grandmother
Grandfather
List Who
*
Mother
Father
Sibling
Child
Grandmother
Grandfather
List Who
*
Mother
Father
Sibling
Child
Grandmother
Grandfather
List Who
*
Mother
Father
Sibling
Child
Grandmother
Grandfather
List Who
*
Mother
Father
Sibling
Child
Grandmother
Grandfather
List Who
*
Mother
Father
Sibling
Child
Grandmother
Grandfather
Please list all allergies/sensitivities
*
Please list all current medications
*
REVIEW OF SYMPTOMS
Please CHECK all that apply
Constitutional
*
Recent Fevers/Sweats
None.
Cardiovascular
*
Blood Clots
Poor Circulation
Swelling of Ankles
Varicose Veins
Venous Insufficiency
None of these.
Endocrine
*
Cuts that take longer to heal
Extreme Thirst
Hyperglycemia
Hypoglycemia
None of these.
Neurological
*
Neuropathy
None.
Allergic/Immunologic
*
Gouty Attack
None.
Psychiatric
*
Depression
None.
Musculoskeletal
*
Arthritis
Fracture
Joint Pain
None.
Arthritis: Where?
*
Fracture: Where?
*
Joint Pain: Where?
*
Skin
*
Bruise Easily
Cellulitis
Chronic Wounds
Itching
Rash
None of these.
Reason for today's visit
*
Is your current problem due to an injury?
*
Please select one...
Yes
No
When did the injury occur?
MM slash DD slash YYYY
Where?
How long has the problem been present?
*
Level of your pain?
*
Please select one...
1 (Tolerable)
2
3
4
5
6
7
8
9
10 (Unbearable)
Does anything improve this problem?
*
Does anything worsen this problem?
*
What treatments have you tried?
*
Have you seen a podiatrist or other physician for this problem?
*
Please select one...
Yes
No
Have you seen a podiatrist for any other problem?
*
Please select one...
Yes
No
If yes, for what?
OFFICE POLICY AND SIGN OFF
I certify that the above information is correct to the best of my knowledge. 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. I will not hold my doctor or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.
*
By checking the box below, I agree to KC Podiatry's
Financial Policy and Release of Info
.
I agree to the terms and conditions.
Name
*
First
Last
Today's Date
*
MM slash DD slash YYYY
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