Foot Care Information

Page 1 of 7
1. First Name(*)
   First Name is Required
2. Last Name(*)
   Last Name is Required
3. Date of Birth(*)
   Day01020304050607080910111213141516171819202122232425262728293031 / Month010203040506070809101112 / Year192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024Date of Birth is Required
4. Address(*)
   Address is Required
5. City(*)
   City is Required
6. Postal Code(*)
   Postal Code is Required
7. Phone Number(*)
   Please enter phone number in format 1234567890 or 123-456-7890
8. Work Phone Number
   Please enter phone number in format 1234567890 or 123-456-7890
9. Cell Phone
   Please enter phone number in format 1234567890 or 123-456-7890
10. Email(*)
    Email Address is Required
11. Employed By
    Invalid Input
12. Occupation
    Invalid Input
13.  

Page 2 of 7
1. Shoe Size
   Invalid Input
2. Shoe Width
   Invalid Input
3. Heel Size
   Invalid Input
4. Shoe Styles
   Invalid Input
5. Height
   Invalid Input
6. Weight
   Invalid Input
7. Change in Weight in past two years
   Invalid Input
8. Leisure Activities (Sports / Exercise)
   Invalid Input
9. Children
   Invalid Input
10. Their Ages
    Invalid Input
11. Their Foot Problems
    Invalid Input
12.  

Page 3 of 7
1. Family Physician
   Invalid Input
2. Date of Last Visit
   Invalid Input
3. Address
   Invalid Input
4. City
   Invalid Input
5. Phone Numbers
   Invalid Input
6. May we send a report for your foot evaluation
   YesNoInvalid Input
7. Name of Health Insurer
   Invalid Input
8. Have you had previous care by a foot specialist?
   YesNoInvalid Input
9. Name
   Invalid Input
10. Address
    Invalid Input
11. Date of last visit
    Invalid Input
12. Previous Foot X-ray
    YesNoInvalid Input
13. When
    Invalid Input
14. Where
    Invalid Input
15. Were you standing
    YesNoInvalid Input
16.  

Page 4 of 7
1. My Foot Problems Involve My
   Left Foot /
   Right Foot /
   Both Feet /
   Other / Invalid Input
2. Briefly describe your current foot problems
   Invalid Input
3. New patients are ofter referred by other physicians or enthusiastic patients and we like to thank them! Whom may we thank for referring you to our office?
4. Name
   Invalid Input
5. Address
   Invalid Input
6.  

Page 5 of 7
1. Are you in good health?
   YesNoInvalid Input
2. Did anyone in your family have foot problems similar to yours?
   YesNoInvalid Input
3. Have you been under a doctor's care in the past two years?
   YesNoInvalid Input
4. If yes, when?
   Invalid Input
5. Do your feet and/or legs cramp, fatigue, or strain easily?
   YesNoInvalid Input
6. Do you have a history of lower back pain?
   YesNoInvalid Input
7. Do your ankles turn or sprain easily?
   YesNoInvalid Input
8. Are the backs or bottoms of your heels painful?
   YesNoInvalid Input
9. Are you regularly tired or exhausted?
   YesNoInvalid Input
10. Do you spend more than 30% of your time on your feet?
    YesNoInvalid Input
11. Do you limit your activity because of your foot pain
    YesNoInvalid Input
12. Do your feet or heels hurt in the morning?
    YesNoInvalid Input
13. Do you smoke?
    YesNoInvalid Input
14. If yes, how much per day?
    Invalid Input
15. Do you drink alcoholic beverages?
    YesNoInvalid Input
16. If yes, how much?
    Invalid Input
17. Are you subject to prolonged bleeding?
    YesNoInvalid Input
18. Is there a family history of DIABETES or ARTHIRITIS?
    YesNoInvalid Input
19. Have you ever had a serious illness or operation?
    YesNoInvalid Input
20. Have ever fainted in a doctor's office
    YesNoInvalid Input
21. FEMALES: Are you pregnant?
    YesNoInvalid Input
22. Have you ever tested positive for Hepatitis?
    YesNoInvalid Input
23. Have you ever tested positive for HIV?
    YesNoInvalid Input
24. Do you take ASPIRIN (ASA), COUMADIN or other blood thinners?
    YesNoInvalid Input
25. Please indicate which blood thinner you take?
    Invalid Input
26.  

Page 6 of 7
1. Have you ever been treated for any of the following (Check all that apply)?
   High Blood Pressure / Diabetes / Stomach Ulcers / Cancer / Liver Problems / Shortness of Breath / Arthritis / Rheumatic Fever / Anemia / Difficulty in Healing / Gout / Tuberculosis / Epilepsy / Heart Problems / Hepatitis / Kidney Problems / Phlebitis / Invalid Input
2. Others
   Invalid Input
3. Do you have allergies to any of the following (Check all that apply)?
   Novocaine or Freezing / Tape Allergy / Latex Allergy / Neomycin or Polysporin / Steroids / Penicillin / Sulfa Drugs / Erythromycin / Aspirin or ASA / Invalid Input
4. Others
   Invalid Input
5.  

Page 7 of 7
1. Acknowledgement: By placing my initials and date I hereby give my permission to Sight N' Steps to examine and treat my feet. I acknowledge that Chiropodist will charge a fees for services that is payable on completion on treatment.
2. Acknowledgement Date(*)
   Acknowledgement Date is Required
3. Acknowledgement Initials(*)
   Acknowledgement Initials are Required
4. Do you want to submit additional foot care information form for family members (common information will be copied)?(*)
   YesNoInvalid Input
5. Please enter the numbers in the image(*)
   
     RefreshInvalid Input