Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
BC Health (MSP) #
Email address
*
Address
*
Apt #
Street Address Line 2
City
Province
Postal Code
Home Phone
*
-
Area Code
Phone Number
Cell Phone
Gender
*
Male
Female
Other
Name of Family Doctor or Nurse Practitioner
*
Shoe Size
How did you hear about our clinic
Extended Medical
Is your visit a result of a motor vehicle accident or a work place injury
*
Yes
No
Date
-
Month
-
Day
Year
Please describe your present foot or ankle problems
How long have you had this problem?
Fill out below questions if applicable
Do you think your job/lifestyle could be contributing to your foot pain?
Have you received previous foot treatment from a podiatrist, orthotist, or foot nurse?
Yes
No
If so when?
Have you had recent x-rays
Emergency Contact / Guardian
Phone Number
-
Area Code
Phone Number
Relationship to Patient
Signature
*
Date
*
-
Month
-
Day
Year
Back
Next
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
BC Health (MSP) #
Pregnant
Yes
No
Breastfeeding
Yes
No
Medical or drug allergies?
*
Yes
No
If yes, please list or tell reception
Have you ever had any of the following? If 'YES, please give brief details (ie date, medications, operation)
Yes / No
Brief Description
Heart Disease
Yes
No
Stroke
Yes
No
Kidney Disease
Yes
No
High Blood Pressure
Yes
No
Arthritis-Osteo
Yes
No
Arthritis-Rheumatoid
Yes
No
Orthopaedic Surgery
Yes
No
Aids/HIV
Yes
No
Hepatitis A/B/C
Yes
No
Circulatory Problems : ( Ex blood clots, leg cramps. poor circulation )
Yes
No
Diabetes
Yes
No
Fractures (Foot/Leg)
Yes
No
Lung Conditions : Ex) Asibrna, COPD
Yes
No
Skin Conditions
Yes
No
Cancer
Yes
No
Any other major medical conditions
Yes
No
Current medications: please list below or give list to reception.
Do you consent to a report of your diagnosis and treatment plan being sent to your family doctor or nurse practitioner if applicable?
*
Yes
No
Signature
*
Date
*
-
Month
-
Day
Year
Submit
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