Midhurstphysio_Chiropody

Full name
Preferred name (if different)
Gender
Address

Address

Street Address Line 2

CityState / Province

Postal Code
Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Date of birth:

DayMonthYear
Date
Email
example@example.com
Occupation
Would you like us to confirm your appointment? (Confirmation via text message)

YesNo
Emergency contact
Relationship
Phone
Format: (000) 000-0000.
How did you hear about us?

Online searchFriend / FamilyPhysicianOther
Do you have third party insurance coverage?

YesNo
Help us help you!Please answer the following foot related questions:
Your current foot problems involve:

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 diagnosed with any of the following?

DiabetesHeart diseaseHigh blood pressureNeuropathyKidney diseaseStrokeArthritisInfectious diseaseCancerNeurological disorderLiver diseaseSkin disorderDepression/AnxietyThyroid diseasePeripheral vascular diseaseGI issues (Stomach)Bleeding disorderImmune disorder
Other
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
What is your current activity level?

SedentaryModerateActive
Please list current regular activities (if applicable):
Have you been treated for any of the following FOOT conditions?

WartsCallusesBunionsHammer toesAthletes footGoutNeuromaFlat feetFoot ulcerAmputationSprain/fracturePlantar FasciitisIngrown nailsToenail fungus
Do you have any known allergies:

YesNo
If yes, please list:
Primary Care Practitioner Information:
Clinic Location
Physician/Nurse Practitioner:
Phone
Format: (000) 000-0000.
Has your doctor treated your foot condition?

yesno
Do you take blood thinners?

YesNo
Current medications (including supplements): If youhave a list our staff can copy and attach it
(If you have a list our staff can copy and attach it)

Additional History

Rows	yes	no	If yes, how much/please explain?
Do you smoke or use recreational drugs?
Do you use alcohol?
Have you had surgery?
Have you ever fainted?
Do you use a mobility aid?

Are you pregnant or nursing?

YesNo
If yes, when is your due date?

MonthDayYear
Date
Patient's Consent

(must be completed and signed before foot exam)
• I understand that the Chiropodist will perform an assessment and provide treatment as clinically indicated

• I understand that treatment risks may include but are not limited to infection, pain, bleeding, delayed healing, recurrence

of condition, and allergic reaction

• I hereby allow photographs of treatment areas for the purposes of medical documentation and treatment monitoring

• I consent to the clinic collecting my personal health information to use for treatment and care

• I consent to the clinic sharing information with my health providers or insurance providers as necessary

• I consent to communication by the clinic via telephone or electronic communication acknowledging privacy risks

• I understand that I may withdraw consent at any time

• 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

• I acknowledge that 24hr notice for cancellation is required and missed appointments may be subject to a fee

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.
Patient's Signature (or guardian):

Clear
Date

MonthDayYear
Date
Should be Empty:

Help us help you!Please answer the following foot related questions:

Primary Care Practitioner Information:

Patient's Consent