Full Name: *

First Name

Last Name

Date of Birth: *

MM

DD

YYYY

Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone (Home):

(###)

###

####

Telephone (Cellphone):

(###)

###

####

Telephone (Work):

(###)

###

####

Emergency Contact Telephone:

(###)

###

####

Family Physician Telephone:

(###)

###

####

Is this problem getting:

Better

Worse

Same

Have you had previous treatment for this problem?

Yes

No

Have you used orthotics/shoe inserts?

Yes

No

Did they help your pain?

Yes

No

Have you ever been treated for:

(Please check all that apply)

Back Pain

High Arches

Corns

Bunions

Neuroma

Heel Pain

Flat Feet

Callus

Hammertoes

Ingrown Toenails

Knee Pain

Warts

Gout

Broken Foot/Leg Bones

Foot/Leg Ulcers

Have you ever had foot x-rays taken?

Yes

No

Do you or have you ever been treated for:

(Please check all that apply)

Heart Trouble

Cancer

Hepatitis

Bone Disease

Thyroid Problems

HIV/AIDS

Stroke

Bleeding Disorder

Liver Disease

Depression

Shortness of Breath

Arterial Vascular Disease

High Blood Pressure

Rheumatoid Arthritis

Skin Disease

Anxiety

Epilepsy

Tuberculosis

Do you have Diabetes?

Yes?

No?

Diabetes is controlled by:

Diet

Drugs

Insulin

Are you pregnant or nursing?

Yes

No

Local Anasthetics. *

(eg. Xylocaine, Novocaine)

Yes

No

Adhesive tape/band-aids: *

Yes

No

I hereby allow and consent to examination and treatment by the Chiropodist. *

Yes

No

I hereby allow myself to be photographed at the discretion of the Chiropodist. *

Yes

No

I consent the Chiropodist to contact my physician/healthcare provider to exchange information relating to my treatment. *

Yes

No

I understand that I am financially responsible for all charges whether covered by my health insurance plan or not. I understand that service fees are payable at the time of service. *

Yes

No

Patients signature (or guardian): *

First Name

Last Name

Today's Date: *

MM

DD

YYYY