Our Offices

Main Office:
2840 Long Beach Blvd,
SUITE 205 Long Beach,
California 90806
Telephone: (562) 426-0376
Fax: (562) 424-4128

Branches:
Palos Verdes
501 Deep Valley Drive
Suite 200 Palos Verdes,
California 90274

Westwood Office:
2288 Westwood Blvd,
Suite 100 Los Angeles,
California 90064

Memorial Wound Healing Center
2801 Long Beach Blvd
Long Beach, CA 90806
(562) 933-3136

Website Services

	Patient Registration To expediate your care at our office, you may want to fill out the following forms before your initial visit
	Request an Appointment Book an Appointment online
	Email The Doctor Feel free to ask any health related question to Doctor Aslemand, it will answered prompty by a health care professional.

Patient Registration

To expedite you care at our office, you may want to fill out these patient forms and complete them before your initial visit.

Patient Information
	Name:
	Gender:	Male Female
	Legal Status:	Single Married Widowed Other
	Address:
	Address 2:
	City:
	State:
	zip:
	Home Phone:
	Work Phone:
	Email:
	Social Security #:
	Birth date:	(yyyy-mm-dd)
	Age:
	Employer:
	Occupation:
	Emergency Contact:
	Phone #:
	Would you like to receive occasional foot health information on Email:	Yes No

Insurance:
	Name of Insured (other than self):
	Birth date:	(yyyy-mm-dd)
	Name of Insured's Employer:
	Insured's work phone number:
	Patient is:	Subscriber Spouse Dependent
	We are required to have a copy of your insurance card(s) on file in order to bill your insurance for you. If we do not have this information on file, you will be billed directly and are solely responsible for all charges. PAyment is due at he time of service. If you submit your insurance card at a later date, we will be glad to bill your insurance company and reimburse you when payment is received.

L & I Injury:
	Date of Injury:
	Type of Injury:	Work Auto Other
	Has a claim been filed?	Yes No Claim #:
	Where was claim filed?
	Cause if Injury:

Referral:
	Referred by:	Friend Web Search Doctor:
	Other:
	Primary Care Physician and Clinic Name:
	Phone #:

Authorization:

The undersigned patient or authorized individual acting on behalf of the patient understand and agrees as follows:

	Dr. John Pagliano and Aslmand is granted permission to release to the insurance carrier, employer, their representatives or referring physician, any information in connection with any treatment rendered to patient, or in patient's behalf at any time such information is requited.
	Patient shall pay to Dr. John W. Pagliano and Aslmand such sums are due, or may become due, for services rendered to the patient. It is understood that in the event patient's insurance company (if there be any) does not make payment, or only a partial payment, this obligation shall be binding personally upon patient.
	The undersigned patient or authorized individual acting on behalf of the patient understands and agrees to pay for services rendered to the above patient and if the account should be transferred to a collection agency/attorney for collection of a delinquent account shall pay reasonable collection costs or attorney fees.

Medical History

Lower Extremity Medical History:
	What is the chief complaint(s) which brings you to our office for medical treatment
	Former foot and ankle physician:
	Name:
	Last Visit:
	Any previous injuries or problems to the feet, ankles or legs?

Symptoms
	Which Side:	Right Left Both
	Type of Pain:	Dull Achy Throbbing Burning Sharp Shooting
	Area of Pain:
	Onset:	Slow Sudden Traumatic
	Duration:
	Has Pain gotten:	Better Worse Stayed the Same
	What Aggravates condition?	Walking Running Standing Shoes
	What have you tried to help the pain?	Changing the Shoes Anti-inflammatories Decrease Activities Other:
	How long does the pain last?
	Have you ever had a similar pain? (describe, including treatments received)

Exercise and Orthotics
	In what athletic Activities do you participate?
	# days per week exercising?
	Do you wear store-bought arch supports?	Yes No
	Do you wear custom orthotics?	Yes No
	If yes, who made them:
	How old are the orthotics:

Allergies and Drug Intolerance:
	Adhesive / Tape
	Aspirin
	Codeine
	Iodine
	Local Anesthetics
	Penicillin
	Sea foods
	Sulfa
	No Known drug Allergies
	Others:

Medications
	List all medications you are taking:

General
	What is your weight:
	What is your height:
	What is your shoe size:

Mental / Emotional
	Eating Disorder:	Yes No
	Anxiety:	Yes No
	Depression:	Yes No
	Psychiatric:	Yes No
	Alcoholism:	Yes No

Surgeries, Injuries, Illnesses
	List surgeries, serious injuries and illnesses not previously listed:

Social History:
	Your Occupation:
	Do You Smoke:	Yes No
	Are you a past smoker?	Yes No
	How much?	packs /
	Years Smoked:
	Drink Alcohol:	Yes No
	How much:
	Recreational Drugs:	Yes No
	What:
	Pregnant or possibly pregnant?	Yes No

General Medical History
Do you or any of your family members have any of the following:
		You	Family Member
	Anemia
	Arthritis Type:
	Artificial Heart Valve or Joints
	Asthma
	Back Problems
	Bleed Easily
	Cancer
	Chemical Dependency
	Chest Pain
	Circulatory Problems
	Diabetes
	Epilepsy
	Fibromyalgia
	Gout
	Heart Disease
	Hemophilia
	Hepatitis
	High Blood Pressure
	HIV Positive
	Kidney Problems
	Leg Problems
	Liver Disease
	Lung / Respiratory
	Menopause
	Mental Illness
	Phlebitis / Clots
	Psoraisis
	Rheumatic Fever
	Stroke
	Thyroid Problems
	Tuberculosis
	Ulcers - Stomach
	Venereal Disease
	Weight Change | Recent : lbs

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