Existing Patient Questionnaire

Use this form to UPDATE your personal information and other changes to your personal information. This form is essential in order to help us to help you. Your PATIENT REFERENCE is in the header of your confirmation email.

"*" indicates required fields

SECTION 1: General Questions

Welcome back to Northernhay Clinic. Please use this form to update your personal information and any changes to your medical history & lower limb symptoms. A good history helps us to help you.

Your Title:*

Your Northernhay Clinic 5 Digit Patient Reference (see appointment confirmation email) e.g: 01892

Your full name:*

First Middle Last

Address:

Street Address Address Line 2 City County Postal code Country

Mobile number:

Alternative phone number (if applicable):

Date of birth:*

Current UK shoe size:*

What is your Occupation?

Retired/ Student etc

Your GP Name:

Prefix Last

GP Address:

Street Address Address Line 2 City County Postcode Country

Have there been any changes to your Family Medical History or your own Medical History?

Do any of the following conditions run in your family: Rheumatoid Arthritis/ Osteoarthritis/ Osteoporosis/ Diabetes/ Hypermobility Syndromes (e.g. Ehlers-Danlos syndrome) - Skin conditions such as Psoriasis can have important and relevant implications in some lower limb conditions. Please make us aware of such skin conditions.

Please tell us about any changes or updates to your medications:

Please list your current medication (if any) here. Please include daily dose, when you started the medication and for what reason the medication was prescribed. If you prefer - you can bring your prescription form along to your appointment.

Do you generally feel fit and well in yourself?

Please note here if you have been feeling unwell and in what way. Please note if you feel any fatigue that is not resolved with sleep/ rest etc.

Have you ever been referred to a Rheumatologist or other specialist since your last visit to us?

This is important as it tells your Podiatrist whether we need to re-refer you as part of our treatment plan to such specialist colleagues.

Do you experience any joint stiffness in the morning that lasts for 60 minutes or more?

Please tell us if you have any other joint swelling or inflammation (not just at the foot & ankle).

Please advise any changes to your surgical history - including dates of operations and procedures you have undergone since your last visit to us:

This is important as it tells your Podiatrist whether we need to re-refer you as part of our treatment plan to such specialist colleagues.

Do you currently have any allergies to anything e.g. Penicillin, Local Anaesthetics etc: *

Anaesthetic/ Plasters/ Latex etc.

Female patients: Are you post menopausal/ do you have irregular periods?

This is important as it tells your Podiatrist whether we might need to be watchful of potential bone density issues.

All patients: Are you Vegetarian, Vegan, Coeliac or do you have any dietary anomalies?

All patients: Do you regularly take part in a sport or recreational activity such as walking, running etc?

Please list the activities that you take part in and advise how many times a week you engage in these activities. If you are a runner please list how often you run and your average mileage.

SECTION 2: Specific questions about your Podiatric problem or reason why you are returning to Northernhay Clinic:

Please give details of any pain or symptoms which you are experiencing as this helps your Podiatry team to better understand your condition. If you have developed any new symptoms or pain since your last visit please list them here.

Are you returning to replace or service your current Foot Orthoses?

If you have no new symptoms and just need an update to your foot orthoses simply select YES here. Alternatively, you can select YES and continue the form to report new symptoms.

1. When approximately did your new symptoms start?

Please detail how long this issue has been going on for.

2. Where are you experiencing these new symptoms? Please be as specific as possible:

e.g. "On the base of my right heel, worse when I get up in the mornings”

3. Please describe the onset of the pain:

Did it come on gradually/ suddenly or can you remember any one thing which may have started the pain? (e.g. sprained ankle or a fall etc)

4. What makes your symptoms worse?

(e.g. standing/ walking/ running etc.)

5. How often are you affected with symptoms?

(e.g. only when I run/ stand/ everyday etc.). Make note here if you are affected with your pain during rest.

6. Do you have any pain that wakes you up from sleep at night?

Pain can sometimes keep us awake but does the pain wake you from sleep?

7. Does any particular action on your part relieve the symptoms either totally or in part:

Please make note of anything you have found to ease the pain (e.g. rest, Ibuprofen, massage etc).

8. Can you describe the pain that you experience?

(e.g. sharp/ dull/ burning/ throbbing etc.)

9. The nerves from your spine/ pelvis travel to the legs and feet - please tell us of any history of back pain:

Give details of any back pain or treatment for Spinal Injuries previously.

10. Can you give the pain a score out of ten: NO PAIN 0 1 2 3 4 5 6 7 8 9 10 AGONY

Try to give us an average pain score if you can. Also include if this pain does ever reduce to a 0/10 (even if only for a short time).

10(a). What is the worst pain out of 10 that you have experienced with this condition? NO PAIN 0 1 2 3 4 5 6 7 8 9 10 AGONY

This is the worst it has been - feel free to comment when this was and provide any other details that you feel are pertinent.

11. Please list any investigations relating to your problems (blood tests/ X-rays/ MRI/ Ultrasound scans etc):

Any reports or photos can be submitted with this form.

Please enter your email address:*

Enter Email Confirm Email

Upload any imaging, reports etc which you would like us to see:

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB, Max. files: 10.

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