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.

History is key

Our Specialist Team ask all of our patients, whether it’s your first time or you’ve seen us for years, to complete a patient questionnaire prior to their consultation or review. This form provides us with all of the relevant information needed in order to tailor the consultation to suit you. It also gives our Podiatry Team an idea of what pathology to look for, highlights what tests or imaging may be needed in future and helps us to get a sense of what might be most helpful in managing your Lower Limb pain.

"*" indicates required fields

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 Title:*

Your Full Name:*

First Middle Last

Address:*

Street Address Address Line 2 City County Postal code Country

Mobile number:*

Alternative phone number (if applicable):

Your Date of Birth:*

Usual UK shoe size:*

Your occupation:

Student / Retired etc

Your GP Name:*

Usually Dr Last

GP Address:

Street Address Address Line 2 City County Postcode Country

How did you hear about us?*

Who has recommended/ referred you to our clinic?Or did you search online i.e. google?

Is there any Medical History in your family we should know about?*

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 medications you are taking:*

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 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.

Have you ever been referred to a Rheumatologist or other specialist?*

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 mornings which lasts 60 minutes or more?*

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

Please advise your surgical history - including dates of operations and procedures you have undergone:*

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

Anaesthetics, 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, like walking, running etc?

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.

1. When approximately did your symptoms start?*

2. Where are you experiencing the 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 pain:*

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)

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 which 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:

Please 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:*

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

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB, Max. files: 10.

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New Patient Questionnaire

SECTION 1: General Questions

Section 2. Specific Questions about your Podiatric Problem

Need help?

Call 01392 259 101

info@northernhayclinic.com