mapleviewphysio_Foot_Patient

Name

TitleFirst nameLast name
Address

Address

Street Address Line 2

CityState / Province

Postal Code
Phone: (H)
Please enter a valid phone number.Format: (000) 000-0000.
Phone: (C)
Please enter a valid phone number.Format: (000) 000-0000.
Date of birth: (D/M/Y)

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

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

InternetFriend / FamilyDoctorOther
Do you have third party insurance coverage (statistics only)

YesNo
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 pressureHIV/AidsCOPDStrokeArthritisCancerCOVID-19Hepatitis/Liver DiseaseSkin disorderDepression/AnxietyThyroid diseaseHigh cholesterolGl issues (Stomach)Autoimmune DisorderNeurological ConditionOther
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 in a day?

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

YesNo
Are there any sports or activities you participate in regularly?

WalkingRunningOther
# of minutes (Walking)
x per week (Walking)
# of kilometers (Running)
x per week (Running)
Have you been treated for any of the following conditions?

WartsCalluses/CornsBunionsHammer toesAthletes footGoutNeuromaFlat feetUlcerationsChildhood Foot ProblemsSprain/fracturePlantar FasciitisIngrown toenailToenail fungus
Do you have any known allergies:

YesNo
If yes, please list:
Patient Physicians & Medical Specialists:
Physician
Phone
Format: (000) 000-0000.
Has your doctor treated your foot condition?

YesNo
Doctor
Phone
Format: (000) 000-0000.
Type of Doctor
Did this doctor refer you to us?

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

Additional History

Rows	Yes	No
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, how much? (Smoking and recreational drugs)
If yes, how much? (Alcohol)
If yes, when is your due date? (Pregnant)

MonthDayYear
Date
If yes, when was your last INR? (Blood thinners)
What was the value? (Blood thinners)
If yes, please explain? (Previous surgeries)
If yes, please explain? (Fainted)
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 Signature (or guardian):

Clear
Date:

DayMonthYear
Date
Mapleview 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:

DayMonthYear
Date
Should be Empty:

Patient Physicians & Medical Specialists: