RonaldW.

Alm,DPM

Alex Morgan
Name___________________________________________
73"
220
Height______________
Weight___________

MedicalHistoryForm

01/25/11
18
4/13/92
Age_________
DateofBirth___________DateofVisit__________

12
Shoesize____________

Dr. Baldick
FamilyPhysician_________________________________________________

OfficeUseOnly_____________/___________________

3/15/2009
DateLastSeen_______________
Specialist(i.e.Cardiologist)____________________________DateLastSeen_______________
DescribethereasonforyourvisitwithDr.Almtoday:Pleaseindicatewhichfoot(circle):
Right Left Both
____________________________________________________________________________________________________________
To have an ingrown toenail removed
____________________________________________________________________________________________________________
Pleaselistallmedicalconditionsyouarebeingtreatedforbyaphysician(i.e.,highbloodpressure,diabetes,cholesterol,asthma):
____________________________________________________________________________________________________________
none
Pleaselistallsurgeries,diagnostictestsandproceduresrequiringanesthesia(i.e.colonoscopy,endoscopy,angiography,pacemaker):
____________________________________________________________________________________________________________
none
____________________________________________________________________________________________________________
Complicationswithanesthesiaorsurgery(check):
Haveyoueverhad:

Nausea/VomitingBleedingHardtimewakingupInfection

1)aMRSAinfection?YesNo 2)HepatitisBorC?YesNo
3)HIV/AIDS?YesNo

YourSocialHistory:
YourOccupation:_____________________________________________________________________________________________
Dietary Server
MaritalStatus:

Married

Single

Divorced

Separated

Widowed

SignificantOther

RecreationalActivities:_________________________________________________________________________________________

Working out hanging out with friends

no
Doyousmokeorchewtobacco?______Ifso,howmuch?_____________Datequit:___________________________________
no
Doyoudrinkalcohol?_______Ifyes,howmanydrinksperweek?______Haveyoubeentreatedforalcoholordrugabuse?______

FamilyMedicalHistoryPleasecheckifafamilymemberhashadthefollowing:
DiabetesHeartdiseaseHighbloodpressureArthritisStrokeAnesthesiaproblemsormalignanthyperthermia
CancerIfyes,whatkind?____________________________________________________________________________________

PersonalMedicalHistoryPleaseindicateYesorNotoallconditions:
Recentfever

Yes
No
Recentweightlossorgain
Yes
No
Diabetes/Borderlinediabetic
Yes
No
Insulinresistant

Yes
No
Dialysis

Yes
No
Cancer

Yes
No
Ifyes,type__________________________
Hospitalizedinthelast5years
Yes
No
Ifyes,why___________________________
Bleedingproblems

Yes
No
Anemia

Yes
No
Psoriasis/Eczema

Yes
No
Sweatyfeet

Yes
No
Hearingproblem

Yes
No
Glaucoma

Yes
No
Frequentsinusinfections
Yes
No
Frequentsorethroats

Yes
No
Shortnessofbreathwithexertion Yes
No
Emphysema/COPD

Yes
No

Asthma/Bronchitis
Yes
No
Bloodclotinlungs/legs Yes
No
Sleepapnea

Yes
No
UseofCPAP

Yes
No
Useofoxygen
Yes
No
HadachestXray
Yes
No

Ifyes,when______________

Ifyes,where_____________
Highbloodpressure
Yes
No
Chestpain

Yes
No
Heartattack

Yes
No
Irregularheartbeat
Yes
No
Heartmurmur
Yes
No
Congestiveheartfailure Yes
No
HadEKGinlast6months Yes
No
Ifyes,where_________________
Frequentinfections
Yes
No
Slowhealing

Yes
No
Liverproblems
Yes
No

Stroke
Yes
Bipolar
Yes
Depression
Yes
Fainting
Yes
Seizures
Yes
Numbfeet
Yes
Jointpain(am) Yes
LowBackPain Yes
RheumatoidArthritis
(RA)
Yes
Osteoporosis Yes
Acidreflux
Yes
Sensitive

stomach
Yes
Ulcer
Yes
BladderinfectionYes
Kidneyproblem Yes
Currently

pregnant
Yes

No
No
No
No
No
No
No
No

No
No
No

No

No
No
No
No

RonaldW.Alm,DPM

AllergiesandMedicationsList

Alex Morgan
Name_________________________________________________________________________

Areyoutakingaspirin?

Yes

No

Areyouallergictoanymedications?

Yes

NameofMedication

TypeofReaction

01/25/2011
DateofVisit___________

MedicationAllergies

No

___________________________________

___________________________________________________________

___________________________________

___________________________________________________________

___________________________________

___________________________________________________________

___________________________________

___________________________________________________________

___________________________________

___________________________________________________________

MedicationsYouAreCurrentlyTaking
MedicationNameandDosage

Timesperday/week?

Reasonfortakingthismedication?

___________________________________

_____________________

________________________________

___________________________________

_____________________

________________________________

___________________________________

_____________________

________________________________

___________________________________

_____________________

________________________________

___________________________________

_____________________

________________________________

___________________________________

_____________________

________________________________

___________________________________

_____________________

________________________________

___________________________________

_____________________

________________________________

___________________________________

_____________________

________________________________

___________________________________

_____________________

________________________________

___________________________________

_____________________

________________________________

___________________________________

_____________________

________________________________

___________________________________

_____________________

________________________________

RonaldW.Alm,DPM

RegistrationForm
01/25
FDateofVisit_______

Alex Morgan
Name___________________________________________

04/13/1992
DateofBirth_____________

HomePhoneNumber:

CellPhone:______________
(208) 503-0181

Email:_______________________
alex_m_413@hotmail.com

__________________________

Preferredmethodofcontact:HomePhone

SS#____________________________
523-85-2401

CellPhone

Email

Isitoktoleaveamessageonphone?YesNo

Employer_________________________
Evergreen Estates

EmployerPhoneNumber_______________
(509) 758-5260

SpousesName___________________________________

SpousesSS#__________________SpousesDOB______________

HomeAddress

MailingAddress(ifdifferent)

_______________________________________________
834 Cedar Ave.

_________________________________________________________

_______________________________________________

_________________________________________________________

Wereyoureferredtousbyanotherphysician/careprovider?NoYesIfyes,who?________________________________

PharmacyName _________________________________________________
PhoneNumber______________________________
509-758-9326
Wasems
Incaseofemergency,pleasecontact:

(208) 791-7745
Name___________________________________________________
PhoneNumber_________________________________
Roben Braun
RelationshiptoPatient_____________________________________________________________________________________
friend

ResponsiblePartyifPatientisaMinororaStudent:
FathersName________________________________

DOB____________

SS#_____________________________

Address____________________________________________________________

HomePhone_____________________

Employer___________________________________________________________

BusinessPh______________________

MothersName________________________________
Melodee Miller

DOB_____________
6/30/1963

SS#_____________________________
538-70-5727

834 Cedar Lewiston Idaho

Address_____________________________________________________________

HomePhone_____________________
(208) 305-7465

Employer____________________________________________________________
Vern Edie

BusinessPh______________________
(208) 748-2206

Alex Bradley Morgan

SubscribersName________________________________

Accident/InjuryInformation
Isyourvisittodayduetoanaccidentorinjury?YesNo

DateofAccident/Injury_________________________________
PlaceofInjuryHomeWorkAuto Other
Howinjured__________________________________________
Accident/InjuryInsuranceInformation

04/13/1992
SubscribersDateofBirth__________________________

IndustrialCarrierName_______________________________

Employer____________________________________________

SecondaryInsuranceName_________________________

Address_____________________________________________

PolicyNumber___________________________________

ClaimNumber________________________________________

GroupNumber__________________________________

Auto/LiabilityCompanyName__________________________

SubscribersName________________________________

Address_____________________________________________

SubscribersDateofBirth__________________________

PhoneNumber________________________________________

ClaimNumber________________________________________

InsuranceInformation

Idaho Medicaid
PrimaryInsuranceName___________________________
PolicyNumber___________________________________
0917959
GroupNumber__________________________________
0917959

NoInsurance(pleasemakepaymentarrangements)

AdjustersName______________________________________

ConsentforTreatment:Iherebyauthorizenecessarymedicalcaretoberenderedtothepatientregisteredhereon.

ReleaseofInformation/FinancialResponsibility:Iherebyassignanyinsurancebenefitsandauthorizethereleaseofmedicalinformationfor

RonaldW.Alm,DPM

PrivacyPracticesForm
thepurposeoftreatment,paymentandhealthcareoperationstoDr.RonaldW.Alm,DPMforservicesrenderedforwhichIacknowledge

financialresponsibility.

_______________
01/21/2011
Date

Alex Morgan

Digitally signed by Alex Morgan

DN: cn=Alex Morgan, o, ou, email=alex_m_413@hotmail.com,
c=US
Date: 2011.01.21 17:10:47 -08'00'

________________________________________________________________________
SignatureofBeneficiary,GuardianorPersonalRepresentative

NOTICEOFPRIVACYPRACTICESACKNOWLEDGEMENT

Iunderstandthat,undertheHealthInsurancePortabilityandAccountabilityActof1996(HIPAA),Ihavecertainrightsto
privacyregardingmyprotectedhealthinformation.Iunderstandthatthisinformationcanandwillbeusedto:

Conduct,plananddirectmytreatmentandfollowupamongthemultiplehealthcareproviderswhomaybe
involvedinthattreatmentdirectlyandindirectly.
Obtainpaymentfromthirdpartypayers.
Conductnormalhealthcareoperationssuchasqualityassessmentsandphysiciancertifications.

IacknowledgethatIhavereceivedyourNoticeofPrivacyPracticescontainingamorecompletedescriptionoftheuses
anddisclosuresofmyhealthinformation.IunderstandthatthisorganizationhastherighttochangeitsNoticeof
PrivacyPracticesfromtimetotimeandthatImaycontactthisorganizationatanytimetoobtainacurrentcopyofthe
NoticeofPrivacyPractices.

IunderstandthatImayrequestinwritingthatyourestricthowmyprivateinformationisusedordisclosedtocarryout
treatment,paymentorhealthcareoperations.Ialsounderstandyouarenotrequiredtoagreetomyrequested
restrictions,butifyoudoagree,thenyouareboundtoabidebysuchrestrictions.

PatientName______________________________________________________________________________________
Alex Morgan
RelationshiptoPatient_______________________________________________________________________________
self

Alex Morgan

Digitally signed by Alex Morgan

DN: cn=Alex Morgan, o, ou, email=alex_m_413@hotmail.com,

c=US
Signature___________________________________________________
Date: 2011.01.21 17:11:17 -08'00'

Date____________________________
01/21/2011

OFFICEUSEONLY
IattemptedtoobtainthepatientssignatureinacknowledgementonthisNoticeofPrivacyPracticesAcknowledgement,butwas
unabletodosoasdocumentedbelow:

Date_______________ Initials__________________

Reason________________________________________________