Midhurstphysio_Chiropody

Name

TitleFirst nameLast name
Address

Address

Street Address Line 2

CityState / Province

Postal Code
Phone: (H)
Please enter a valid phone number.
Phone: (C)
Please enter a valid phone number.
Phone: (W)
Please enter a valid phone number.
Date of birth:

DayMonthYear
Date
Email
example@example.com
Occupation

Would you like us to confirm appointment?

	yes	No
Email
Phone

Emergency contact
Relationship
Phone
How did you hear about us? (please specify)

InternetFriend / FamilyRepeat Patient to ClinicDoctorOther
Do you have third party insurance coverage? (statistics only)

YesNo
Type a question

Left foot onlyRight foot onlyBoth feetNailsSkinFoot pain
Please explain your current foot problem:
Is this problem getting:

WorseBetterNo change
Have you ever had treatment for this problem?

yesNo
Have you had foot x-rays:

yesNo
When:
Have you ever been treated for: (systemic conditions)

DiabetesHeart diseaseLiver diseaseHigh blood pressureSkin disorderHIV/AidsArthritisCancerShortness of breathStrokeHigh cholesterolDepressionStomach / Bowel issuesNone ApplyOther
Cont.
HbA1c: __________%
FBG: __________ mmol/L
What is your current height:
What is your current weight:
What is your current shoe size:
On average how much are you on your feet?

20%40%60%80%100%
What type of WORK shoes do you wear most:
What type of LEISURE shoes do you wear most:
Do you use custom orthotics (shoe inserts)?

yesNo
Check any sports or activities you participate in regularly:

WalkingRunningSoccerSkiingAerobicsGolfBasketballOther
How long do you walk:
minutes
How far do you run:
______ Km
How far do you run:
______ ✗ per week
Have you ever been treated for: (foot specific conditions)

WartsCallusesBunionsHammer toesHeel painGoutCornsFlat feetAnkle injuryChildhood Foot ProblemsBroken feet / legNeuromaIngrown nailsUlcerations
Do you have any known allergies:

YesNo
If yes, please list:
Patient Physicians & Medical Specialists:
Physician
Phone
Has your doctor treated your foot condition?

yesno
Doctor
Phone
Type of Doctor
Did this doctor refer you to us?

yesno
Please list your current Rx medications:
(If you have a list our staff can copy and attach it)

Social History

	yes	no	If yes, how much/please explain?
Do you smoke or use recreational drugs?
Do you use alcohol?
Are you pregnant?
Do you take blood thinners?
Have you had previous surgeries?
Have you ever fainted ?

If yes, when is your due date?

MonthDayYear
Date
If yes, when was your last INR?
What was the value?
Patient's Consent: (must be completed and signed before foot exam)

I hereby allow and consent to examination and treatment by the Chiropodist and allow photographs of treatment areas to be taken for the purposes of monitoring my foot conditions.I hereby allow the Chiropodist to contact my physician for any pertinent information required relating to my treatment or medical information.I hereby allow the Chiropodist to send my physician or health care professional reports, as necessary, regarding my foot exam and treatment plan.I understand that Chiropody is not an OHIP covered service and 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 service is provided.
Patient's Consent: (must be completed and signed before foot exam)

I hereby allow and consent to examination and treatment by the Chiropodist and allow photographs of treatment areas to be taken for the purposes of monitoring my foot conditions.

I hereby allow the Chiropodist to contact my physician for any pertinent information required relating to my treatment or medical information.

I hereby allow the Chiropodist to send my physician or health care professional reports, as necessary, regarding my foot exam and treatment plan.

I understand that Chiropody is not an OHIP covered service and I am financially responsible for all charges whether covered by my health insurance plan or not.

Iunderstand that service fees are payable at the time service is provided.
Patient's Signature (or guardian):

Clear
Date

MonthDayYear
Date
Midhurst Foot Clinic promises to treat your personal information with respect. Our privacy protocols comply with provincial privacy legislation, the standards of the College of Chiropodists of Ontario, and the law.

We will help you to the best of our ability investigate any potential coverage for our services but ultimately it is the patients responsibility to be aware of their own insurance plan.
Chiropodist Signature:

Clear
Date

MonthDayYear
Date
Should be Empty:

Patient Physicians & Medical Specialists: