New patient questionnaire

Use this form to provide us your personal information and specific Podiatric history. This form is essential in order to help us to help you.

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SECTION 1: General Questions

Our Podiatrists would like as much information as possible about your medical history to personalise your consultation and treatment. This initial information is vital to give us an insight into your problems before you attend. The foot and limb are affected by all systems in the body. The more information we have about your health the better.
Your Full Name:*
Address:*
Your Date of Birth:*
Student / Retired etc
Your GP Name:*
GP Address:
Who has recommended/ referred you to our clinic?Or did you search online i.e. google?
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 make 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.
Anaesthetics, 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 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

Please give details of any pain or symptoms that you are experiencing as this helps your Podiatry team to better understand your condition.
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 that you think 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.)
Please 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.
Please enter your email address:*
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