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.

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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 full name:*
Address:
Date of birth:*
Retired/ Student etc
Your GP Name:
GP Address:
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 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.
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.
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.
Please tell us if you have any other joint swelling or inflammation (not just at the foot & ankle).
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.
Anaesthetic/ Plasters/ Latex etc.
This is important as it tells your Podiatrist whether we might need to be watchful of potential bone density issues.
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.
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.
Please detail how long this issue has been going on for.
e.g. "On the base of my right heel, worse when I get up in the mornings”
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)
(e.g. standing/ walking/ running etc.)
(e.g. only when I run/ stand/ everyday etc.). Make note here if you are affected with your pain during rest.
Pain can sometimes keep us awake but does the pain wake you from sleep?
Please make note of anything you have found to ease the pain (e.g. rest, Ibuprofen, massage etc).
(e.g. sharp/ dull/ burning/ throbbing etc.)
Give details of any back pain or treatment for Spinal Injuries previously.
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).
This is the worst it has been - feel free to comment when this was and provide any other details that you feel are pertinent.
Any reports or photos can be submitted with this form.
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