Get Ucla Foot/ankle - New Patient Intake Form 2013-2026

Filling out the UCLA Foot/Ankle - New Patient Intake Form online is a crucial step in receiving the care you need. This guide provides detailed instructions to ensure you complete the form accurately and efficiently.

Follow the steps to fill out your intake form with ease.

1. Press the ‘Get Form’ button to access the UCLA Foot/Ankle - New Patient Intake Form and open it in the digital editor.
2. Begin by entering your personal information in the designated fields, including your name, date of birth, occupation, and age. Ensure that all entries are accurate and reflect your current details.
3. Indicate whether you were referred to this office and, if applicable, provide the name of the referring party.
4. Fill in the information for your Internist or Primary Care Physician, including their full name, phone number, and fax number.
5. Address your chief complaint by specifying which side of your foot or ankle is bothering you, describe the problem that brought you in, and note how long you have been experiencing this issue.
6. If your chief complaint includes pain, answer the related questions about the location and intensity of your pain, using the provided scale from 0 to 10.
7. Respond to the activity-related symptoms section by indicating whether you experience pain at rest or with regular activities, and answer yes or no to each symptom listed.
8. Provide details about any additional symptoms you may have experienced, noting if you encounter stiffness, numbness, or other concerns.
9. Indicate any treatments you have previously tried, including medications, physical therapy, or injections, and provide relevant details.
10. Complete the section on imaging and diagnostic studies. Include any MRIs or X-rays you have had and their findings, as well as any other relevant tests.
11. List all medications you are currently using, followed by any allergies you may have.
12. Confirm any past or present medical issues by answering the questions regarding significant health concerns. Describe all affirmative responses as needed.
13. Detail your surgical history, noting any past surgeries or hospitalizations and the dates they occurred.
14. Respond to lifestyle questions regarding alcohol and tobacco use, including frequency and duration.
15. Complete the family history section and provide your height and weight as requested.
16. Finally, review all the information you have entered for accuracy before saving your changes. You will have the option to download, print, or share the completed form.

Take the first step towards your care by completing the UCLA Foot/Ankle - New Patient Intake Form online today.