Patient Details 1Details & Medical History2Main Concern(s)3Other Areas of Pain Personal Details:TitlePlease selectDrMissMrMrsMsMstFirstname(Required)Surname(Required)Street Address(Required)Suburb(Required)State(Required)VICACTNSWSATASQLDWANTPost Code(Required)Best Contact Number(Required)Email Address(Required) Can we email you?Please selectNoYesDate of Birth(Required) DD slash MM slash YYYY OccupationParent Guardian (if under 16)Address (if different from above)Please selectNoYesParent Guardian AddressEmergency ContactEmergency PhoneMedicare No.Private HealthConcessionIs your Account paid by third party?Please selectNoYesEntity NameContact NameClient NumberPresent Medical Details:Your DoctorWhen was your last visit?Doctor's AddressAre you happy for us to keep your doctor informed?Please selectNoYesHave you seen a Podiatrist before?Please selectNoYesWhen?Your Profile:Your assessment includes a computerised plantar pressure assessment which requires the following information to calibrate the equipment.WeightkgsHeightcmsShoe SizeEuroReferral:We appreciate people who feel that our care is worth sharing with their friends and family. This is how our practice continues to grow and we like thanking the people who refer to us.How did you hear about us?Please enter the details after chosing one more options Health Professional Health Professional NameMedical CentreHow did you hear about us? Online How did you hear about us? Friends/Family Friends/Family NameHow did you hear about us? Other Please specify:Medical Details:(Please specify if applicable):DiabeticPlease selectGestationalPre-DiabeticType 1Type 2Diabetic other(e.g Foot Ulceration)Neurological disorderPlease selectMSParkinsons DiseasePeripheral NeuropathyStokeNeurological otherArthritisPlease selectGoutOste/AOsteopenia/ porosisRheumatoid/AArthritis otherInjury RehabilitationPlease selectShort-term programMedium-term programLong-term programRehabilitation otherHeart disorderPlease selectBy-pass SurgeryHeart AttackPace MakerPeripheral Vascular/ Arterial DiseaseVaricose VeinsHeart disorder otherAre there any major Foot or Medical Problems in your Family?Please selectNoYes Your Current Concern:It is important for us to fully understand all the details of your condition. Please take time to note fully and accurately the details of the area/s of your pain.Previous injuries, accidents or surgery(To feet, legs, and or back. Please list in date order)Your Main ConcernDescribe your main concern:How did it start?Please selectInjuryUnknownFrom another conditionDescribe your pain out of 10(1 = not a lot, 10 = severe):Please select0 - 33 - 55 - 88 - 10How long have you had this problem?Please selectDaysWeeks< 3 Months3-6 Months6-12 Months> 12 MonthsEpisodicIs it getting?Please selectBetterSameWorseIs the pain? Sharp Sharp episodes with background continuous pain Aching Pins & Needles Dull Burning Throbbing When is the problem worse? First few steps after rest End of the day Night During Activity After Activity All Day What activities / sports do you do at present?Have you increased your time in sports activity recently?Please selectNoYesOr intensity of the activity?Please selectNoYesWhat makes things worse?What makes things better?Has it occurred before?Please selectNoYesWhat made it better then?Have you grown in height in the last 3-6 months?Please selectNoYesWhat do you believe is causing your pain?Do you think you will get better?Take some time thinking about the following questions in this next section as this will make up the goal that we both will work towards for you to achieve and improve your quality of life.What would you like to be able to do which you are currently not able to do because of the pain / condition, where/which and why?(e.g. I aim to return to daily pain free walking in the park in 6 weeks because it makes me feel alive.)Rate how much the pain is preventing / reducing your ability to perform your preferred activities.Please select0 (Not al all)12345678910 (Definitely)Rate this problem; How important is this to be addressed out of 10?(e.g. I really miss my walking (9/10), because of my sore foot as it was a time out for me, and I miss meeting up with my friends in the park.)Please select0 (Not urgent)12345678910 (Most urgent)And, how urgent?(e.g. Within 8 weeks)Please selectWithin 1 weekWithin 2 weeksWithin 4 weeksWithin 6 weeksWithin 8 weeksWithin 10 weeksWithin 12 weeksWithin 3 monthsWithin 6 monthsWithin 9 monthsWithin 12 monthsRate how confident you are to make small changes to achieve this goal out of 10?(e.g. I rate my level of confidence in getting better as 8/10, as I know others like me, who have gotten improvement from this clinic.)Please select0 (Not confident)12345678910 (Fully confident)If you have responded less than 7 to the above question, please select from the list:Please selectUnsure what to doTried other treatments without successTried different shoes without successFind it difficult to make too many changesThink it will be too hard to achieveAm at a very busy point in my lifeOtherIf 'Other', please specify:Please note any practitioners you have already seen about this problem and what tests/ treatment has been done: Other Areas of Pain such as Hips, Back or NeckMany people have other areas of pain over their body such as neck, lower back or hip pain, chronic headaches, etc. We are interested in these other areas as we treat you holistically, knowing that recent medical research indicates that normal functions, such as walking, involves the whole body from head to the toes!Describe your other concerns/pain:How long have you had this problem?Is it getting?Please selectBetterSameWorseHow did it start?Is the pain?Please selectMildModerateSevereWhen is this other problem worse? Morning Evening Night During/After Activity or Sport All Day Day & Night What makes things worse?What makes things better?Please note any practitioners you have already seen about this problem and what tests/ treatment has been done:Other Information:If there is any further information you want to give us, please write below:We look forward to helping you achieve what you can, working with you step by step towards your desired outcome.NameThis field is for validation purposes and should be left unchanged.
