Andrea Simons, DPM Davina Cross, DPM Schavey Road, Suite 2, DeWitt, MI (517) Patient History. Name: (First) (MI) (Last)

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Today s : Andrea Simons, DPM Davina Cross, DPM 13105 Schavey Road, Suite 2, DeWitt, MI 48820 (517) 668-6166 Patient History of Birth: Social Security #: Name: (First) (MI) (Last) Prefers to be called Address: (Street) (City) (State) (Zip) Home Phone: Cell Phone: Work Phone: Preferred Phone: Email: Employer: Marital Status: Occupation: Spouse s name: Guardian s name (if patient is a minor): Address (if different from above): (Street) (City/State/ZIP) Person to contact in case of an emergency: Relationship to patient: Phone: Address: (Street) (City) (State) (Zip) Referred By:

(Please Circle) Race: African American, American Indian/Alaskan, Native Asian, Pacific Islander, White, Other/Decline to Disclose Ethnicity: Hispanic/Latino, Non- Hispanic/Latino, Decline to Disclose What is your foot or ankle problem? When did the problem start? How have you treated the problem? Weight: Height: Shoe Size: Are you in: ( ) good health ( ) fair health ( ) poor health Are you prone to prolonged bleeding or healing difficulties? ( ) yes ( ) no Do you bruise easily? ( ) yes ( ) no Primary Care Physician s name and address: Last time you saw your Primary Care Physician What medications are you currently taking? (If you have a list with you, we can copy the list.) Name Dose Frequency Are you allergic to any medications? If yes, which ones? Preferred Pharmacy?

Are you pregnant? ( ) yes ( ) no Do you smoke? ( ) yes ( ) no If yes, how much? Do you drink alcohol? ( ) yes ( ) no If yes, how much? Do you take any illicit drugs? ( ) yes ( ) no If yes, which ones? Do you have a family history of: Diabetes ( ) Blood clots/bleeding Disorder ( ) Heart disease ( ) Problems with anesthesia ( ) Cancer ( ) Hypertension ( ) Peripheral Arterial Disease ( ) Other ( ) Past Medical History (Do you currently or have you ever had any of the following): Heart Disease ( ) Asthma ( ) High Cholesterol ( ) Neuropathy ( ) Anemia ( ) Stomach ulcer/gerd ( ) Hypertension ( ) Stroke ( ) Kidney Disease ( ) Bleeding Disorder ( ) Blood Clot ( ) Liver Disease ( ) Pneumonia ( ) Diabetes ( ) Epilepsy ( ) Thyroid Disease ( ) Venereal Disease ( ) Arthritis ( ) Gout ( ) Tuberculosis ( ) Eye Disease ( ) Pregnancy ( ) HIV ( ) Cancer ( ) Type Other _ Diabetic History: Type: of Onset: Complications due to Diabetes? Past Surgical History: Problems with anesthesia? Is there anything else you feel we should know? I hereby give permission to Dr. Andrea Simons and Dr. Davina Cross to treat and/or photograph my foot. : of Patient or Guardian

Insurance Information Do you have a copay? Yes or No If yes, fill in amount here $ Primary Insurance Company Policy Holder SSN# Your Relationship to the Policy Holder Enrollee ID# or Medicare Claim Number Group # Subscriber s Employer Policy Holder s Birthdate Secondary Insurance Company Policy Holder SSN# Your Relationship to the Policy Holder Enrollee ID# Group # Subscriber s Employer Policy Holder s Birthdate Release and Assignment of Benefits I hereby authorize the release of any medical information necessary to process my insurance claim. I authorize payment to be made directly to Looking Glass Foot & Ankle Center, P.C., tax ID # 27-2516761. I have been provided with a copy of the Looking Glass Foot & Ankle Center Financial Policy and understand that I am financially responsible for any and all balance(s) not covered by insurance carriers or out-of-pocket expenses at the time of service.

Patient Name: of birth (Please Print) PAYMENT I acknowledge that I have been offered the Financial Policy and I acknowledge it is my responsibility to pay for any services I receive from Looking Glass Foot and Ankle Center. _ MEDICARE PATIENTS ONLY I authorize and request that payment of authorized Medicare benefits be made to Looking Glass Foot and Ankle Center on my behalf for any services furnished to me by a provider of Looking Glass Foot and Ankle Center. _ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - DO YOU HAVE AN ADVANCED DIRECTIVE? Yes No For more information regarding Advanced Directives please visit www.caringinfo.org LOOKING GLASS FOOT AND ANKLE CENTER NOTICE OF PRIVACY PRACTICE I acknowledge that I have been offered the Looking Glass Foot and Ankle Center Notice of Privacy Practices Patient Name (please print) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - COMMUNICATION OF YOUR PROTECTED HEALTH INFORMATION If you want us to speak with another individual including your primary care physician about your care, please list their name, relationship to you, and phone number: Name Relationship Phone Number _

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