Foot Care Information Positive SSL Seal

    Page 1 of 7

  1. First Name(*)
    First Name is Required
  2. Last Name(*)
    Last Name is Required
  3. Date of Birth(*)
    / / Date 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
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  12. Occupation
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  13. Sight N' Steps Location
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  14.  

    Page 2 of 7

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

    Page 3 of 7

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

    Page 4 of 7

  1. My Foot Problems Involve My



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  2. Briefly describe your current foot problems
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  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
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  5. Address
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  6.  

    Page 5 of 7

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

    Page 6 of 7

  1. Have you ever been treated for any of the following (Check all that apply)?
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  2. Others
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  3. Do you have allergies to any of the following (Check all that apply)?
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  4. Others
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  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)?(*)
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  5. Please enter the numbers in the image(*)
    Please enter the numbers in the image
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