New Patient History Form

Welcome to the McRae Foot Health Centre. We are committed to providing exceptional foot care for people of all ages. Please help us get to know you by providing the following information.
First Name:	Middle Name: Last Name:
Date of Birth: ------ Day ------ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   ------ Month ------ January Febuary March April May June July August September October November December   ------ Year ------ 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915
Address:	City: Postal Code:
Telephone (Home):	Telephone (Work): Cell Phone:
Occupation:	Email Address:
Emergency Contact Name:	Telephone:
Family Physician:	Address: Telephone Number:
Insurance Provider:	Policy Number:
How did you hear about our clinic?	Select Doctor Friend/Family Website     Other:
Please answer the following foot questions:
Do your foot problems involve:	Please Select Right Foot Left Foot Both Feet
Why are you here today? Please explain your current problem(s):
Is this problem getting:	Better   Worse   Same
Have you had previous treatment for this problem?	Yes   No
Who did you see?	Select Chiropodist Podiatrist Doctor     Other:
Have you ever had 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 Heel Pain Knee Pain High Arches Flat Feet Warts Corns Callus Gout Bunions Hammertoes Broken foot/leg bones Neuroma Ingrown Toenails Foot/leg ulcers
Have you ever had foot x-rays taken?	Yes   No
When/Where?
What is your current:	Weight: Height: Shoe Size:
Do you or have you ever been treated for: (Please check all that apply) Heart Trouble Stroke High Blood Pressure Cancer Bleeding Disorder Rheumatoid Arthritis Hepatitis Liver Disease Skin Disease Bone Disease Depression Anxiety Thyroid Problems Shortness of Breath Epilepsy Tuberculosis HIV/Aids Arterial Vascular Disease Diabetes Controlled by: Diet Drugs Insulin When were you diagnosed?
Other general medical conditions:
Are you pregnant or nursing?	Yes   No
Please list previous surgeries with dates:
Please list your current medications:
Do you have any known allergies to:
Local Anasthetics (eg. Xylocaine, novocaine)	Yes   No
Adhesive tape/band-aids	Yes   No
Other drug allergies:
McRae Foot Health Centre will treat your personal information with respect. Our privacy protocols comply with privacy legislation, College of Chiropodists of Ontario standards and the law. Be assured that everyone in our office is committed to ensuring that you receive the best quality foot care.
Patient Consent	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):       Date:
Type text as it appears:

Our Benefits

• Restore natural function
  Using custom made orthotics, your feet
  will feel as great as they used to.
• Release joint tension
  Orthotics helps to realign foot and ankle bones to neutral positions.
• Get back to enjoying your life!
  Feel better and enjoy all your favorite
  daily activities.