Complete A Patient Questionnaire | Podiatrycliniconline

SECTION 1: General Questions

Our Podiatrists like as much information as possible about you to personalise your 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)

Patient date of birth*

DD

MM

YYYY

Usual UK shoe size*

Your occupation /student / retired ?

Your GP Name*

Usually Dr First 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/ Hyper-mobility Syndromes (e.g. Ehlers-Danlos syndromes) Skin conditions such as Psoriasis can have some important and relevant effects on your feet/ legs/ tendons and joints etc. Please make us aware of such skin conditions.

Please tell us about any medications you are taking*

Please list your correct medication (if any) here. Please include daily dose, when you started the medication, who prescribed it and for what reason the medication was prescribed. Please either email or bring in written form to the appointment:

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.

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: *

Anaesthetic, nuts, latex etc. It’s important that we know

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 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 that you take part in and advise how many times a week you engage in these activities (include distance of runs etc.)

Section 2. Specific Questions about your Podiatric Problem

Please give details as this helps your Podiatry team with your treatment.

1. When approximately did your symptoms start?*

If not applicable eg: ongoing flat foot - state N/A.

1. (a) Where are you experiencing the symptoms - please be as specific as possible*

e.g. “in my right heel, worse when I get up in the mornings”)

2. What makes your symptoms worse:*

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

3. How often are you affected with symptoms:*

(e.g. only when I run/ stand/ everyday etc.)

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

Please be sure to mention any night pain or rest pain.

5. Can you describe the pain that you experience*

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

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

Give details of any Back Pain or treatment for Spinal Injuries previously:

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

This should be the pain score as an average of the last week or so.

7.(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 is pertinent.

8. Please list any investigations e.g. blood tests or X-rays/ MRI or Ultrasound scans relating to your problems:

Any reports can be submitted for with this form.

Please enter your email address*

Enter Email Confirm Email

Upload any imaging reports etc that you wish us to see

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