Chiropody Patient Intake Form

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McQuistan Chiropody - Patient Intake Form
Welcome to McQuistan Chiropody! Please help us get to know you better by providing the following information:
First name: _____________________________________ Last name: ___________________________________Title: __________
Address: ____________________________________________ City: ______________________ Postal code: _________________
Phone: (H) ____________________________ (C) __________________________________ (W) ____________________________
Date of birth: (D/M/Y) _____________________________________ Occupation: ________________________________________
How would you like appointments confirmed?
Email address: ____________________________________________
Phone
Emergency contact: First name: _________________________________ Last name: ____________________________________
Relationship: __________________________ Phone: ________________________________
How did you hear about our clinic?
___________ □
________________
Newspaper
Internet
Doctor
Other (please specify)
Friend / family
Help us help you!
What is your current:
Please answer the following foot-related questions:
Height: _________ Weight: __________ Shoe size: _______
Your foot problems involve:
On average, how often are you on your feet?:
□ Left foot only
□ Right foot only
□ Both feet
□ 20%
□ 40%
□ 60%
□ 80%
□ 100%
Why are you here today? Explain your current foot problem:
What type of shoes do you wear most?:
___________________________________________________
Work: ___________________ Leisure: ____________________
___________________________________________________
Do you use custom orthotics?: (shoe inserts)
Yes
No
Is this problem getting:
Check any sports or activities you participate in regularly:
□ Worse
□ Better
□ Same / no change
□ Walking
How long do you walk?: _____________minutes
Have you ever had treatment for this problem?
Yes
No
□ Running
How far do you run?: ______km ____X per week
□ Soccer
□ Skiing
□ Aerobics
□ Golf
Have you had foot x-rays?:
Yes
No When:
Other: ______________________________________________
Have you ever been treated for: (systemic conditions)
Have you ever been treated for: (foot specific conditions)
□ Diabetes
How long have you had it?:_____________
□ Warts
□ Gout
□ Broken feet / leg
□ Heart disease
□ Liver disease
□ Calluses
□ Corns
□ Neuroma
□ High blood pressure □ Skin disorder
□ Bunions
□ Flat feet
□ Ingrown nails
□ HIV/Aids
□ Arthritis
□ Hammer toes □ Ankle injury □ Ulcerations
□ Cancer
□ Shortness of breath
□ Heel pain
□ Childhood foot problems
□ Stroke
□ High cholesterol
Do you have any known allergies to:
□ Depression
□ Stomach / bowel issues
Anesthetics
Yes
No
Tape / Band-Aids
Yes
No
□ None apply
□ Other: _____________________
Cont. _______________________________________________
No allergies
Other: ______________________________
Continued on other side...

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