Keller Office
 (Centerview Office Park)
1141 Keller Pkwy, Suite C
Keller, TX 76248
 (817) 741-4800

Grapevine Office
 1600 Lancaster Drive
Suite 102
Grapevine, TX 76051
 (817) 481-4000

Patient Information
Date *
ALL INFORMATION MUST BE COMPLETED PRIOR TO SEEING PHYSICIAN
Patient Last Name *
Patient First Name *
Patient Middle Initial *
Social Security Number
Street Address *
City *
State *
Zip *
Phone * - -
Alternate Phone - -
Driver's License
Email Address
Age *
Gender *
Marital Status *
Who May We Thank For Referring You? *
Was Patient's Condition Related To:
If Accident, Date of Accident
Patient's Employer or School
Employer Address
Employer Phone - -
Spouse
Spouse/Significant Other Name *
Date of Birth *
Social Security Number
Employer Name
Employer Address
Employer Work Phone - -
Name of Nearest Relative
Nearest Relative Home Phone - -
Nearest Relative Work Phone - -
Nearest Relative Address
Guarantor
Person Responsible for Patient *
Date of Birth *
Social Security Number
Relationship to Patient *
Street Address *
City *
State *
Zip *
Phone * - -
Driver's License
List Three Emergency Contacts
#1 Name
#1 Phone - -
#1 Relationship
#2 Name
#2 Phone - -
#2 Relationship
#3 Name
#3 Phone - -
#3 Relationship
Patient's Medical History
Name *
Age *
Height *
Weight *
Shoe Size *
What Condition Are you Being Seen For Today? *
Where Is It? *
How Long Have You Had It? *
What Started It? *
What Makes It Worse? *
What Treatment Have You Had? *
What Are Your Goals Of Treatment? *
Have You Been Treated By Another Physican? *
If You Answered "Yes" Above:
Who?
For What?
When?
MEDICAL HISTORY REVIEW: Do You Have Any Of The Following?
Diabetes   Yes
  No
High Blood Pressure *   Yes
  No
Rheumatic Fever   Yes
  No
Cancer   Yes
  No
Tuberculosis   Yes
  No
Gout   Yes
  No
Heart Problems   Yes
  No
Asthma   Yes
  No
Phlebitis   Yes
  No
Kidney Disease   Yes
  No
Arthritis   Yes
  No
HIV Positive   Yes
  No
Circulatory Problems   Yes
  No
Glaucoma/Eye Problems   Yes
  No
Keloids   Yes
  No
Stroke   Yes
  No
Seizures   Yes
  No
Hepatitis/Liver Problems   Yes
  No
Paralysis   Yes
  No
Last Tetanus Immunization   Yes
  No
Have You Had Any Of The Following Conditions Recently?
Currently Pregnant   Yes
  No
Anemia *   Yes
  No
Problems Hearing *   Yes
  No
Frequent Sore Throat *   Yes
  No
Frequent Urination *   Yes
  No
Vericose Veins *   Yes
  No
Swollen Glands *   Yes
  No
Numbness or Neurologic Problem *   Yes
  No
Excessive Bleeding *   Yes
  No
Large Weight Change *   Yes
  No
Sinus Problems *   Yes
  No
Digestive Problems *   Yes
  No
Leg Cramps *   Yes
  No
Thyroid Problems *   Yes
  No
Leg Swelling *   Yes
  No
Frequent Anxiety or Psychiatric History *   Yes
  No
Poor Healing *   Yes
  No
Shortness of Breath *   Yes
  No
Chest Pain *   Yes
  No
Stomach Ulcers *   Yes
  No
Joint Pain or Stiffness *   Yes
  No
Back Pain *   Yes
  No
Immune System Problems *   Yes
  No
Excessive Fatigue *   Yes
  No
Frequent Headaches *   Yes
  No
Excessive Coughing *   Yes
  No
Frequent Thirst *   Yes
  No
Muscle Weakness *   Yes
  No
Skin Rashes *   Yes
  No
Other Problems or Conditions Not Listed Above:
Family Doctor and Other Doctors You Are Currently Seeing: *
List All Previous Surgeries, If Any:
HISTORY OF MEDICATION
List All Medications, How Often You Take Them, The Strength, and Why: *
ALLERGIES
Novacaine *   Yes
  No
Penicillin *   Yes
  No
Tape/Band Aids *   Yes
  No
Aspirin *   Yes
  No
Iodine *   Yes
  No
Codeine *   Yes
  No
Sulfa *   Yes
  No
Metal *   Yes
  No
Other (food, fabric, etc.) *   Yes
  No
If Other Is Yes, Please Explain:
Other Antibiotics *   Yes
  No
SOCIAL HISTORY
List Exercise, Sports, or Recreational Activities That You Are On Your Feet: *
Marital Status *
Alcohol Use *
Do You Smoke? *
If You Smoke, How Much?
Recreational /Street Drug Use *
FAMILY HISTORY: Please list all diseases to your family including heart disease, diabetes, rheumatoid diseases and arthritis and genetic problems
Grandparents *
Father *
Mother *
Siblings *
Children *
Additional Comments
Type Your Name Here *
Date
I have read and understand the financial policies for Alliance Foot and Ankle Specialists as set forth in the preceding.
Electronic Signature *
Please type the code shown in the image: *
"Superior Medicine Diagnosis
Healing
Foot & Ankle Pain Relief

...PERIOD."

Dr. Richard A. Nichols

  About Dr. Nichols

  New Patients

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  Footprints Newsletter

  Appointments

Our friendly and courteous staff is ready to serve you now!  To better assist your decision to allow us the opportunity of working with you, please view our Surgical Animations for more explanation about specific procedures.

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Alliance Foot & Ankle Specialists, Grapevine Podiatry, Keller Podiatry
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