patient-form

Complete a New Patient Information Form

Pocono Foot & Ankle Consultants, P.C. is currently accepting new patients. For your convenience, you can fill out the online form below or download a blank new patient information form to fill out and bring with you to your first appointment.

Patient Name (First, Initial & Last)*
Patient Street Address*
Patient City*
Patient State*
Patient Zip*
Patient Telephone #*
Occupation/Employer
Patient Work #
Date of Birth
Age
Sex
Marital Status
Race:
 Asian WhiteHispanic/Latino Black/African American American Indian Refuse
Do you have a caregiver? (Provide name and Telephone)
How did you hear about our practice?
 Friend Internet Yellow Pages
Doctor Referral (Dr.'s Name and phone number)
Please explain reason for visit
Who is your family physician (including phone #)?
Name of Pharmacy you use (including phone #)
Please list any allergies you have to medication
Do you smoke?
Do you consume alcohol?
Family History of:
 Cancer Diabetes Arthritis Vascular Problems
Have you ever been treated for
 Diabetes Heart disease Stroke High blood pressure Arthritis Epilepsy Rheumatic fever Kidney disease Liver disease Thyroid disorder Neurological disorder Cholesterol problems AIDS
Please list any serious illnesses or operation
Please list ALL medication
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