Patient Details - Plantar Pressure Screening 1Details & Medical History2Main Concern(s) 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 Your Profile:Your assessment includes a computerised plantar pressure assessment which requires the following information to calibrate the equipment.WeightkgsHeightcmsShoe SizeEuroMedical 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 selectNoYesWho has referrred you for this assessment? 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)Describe 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?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.
