Which of our clinical partners has suggested an online consultation and opinion with a 3D Footprint Podiatrist? It is important for us to collaborate and support clinical partners with your further treatment.
Do any of the following conditions run in your family:
Rheumatoid Arthritis/ Osteoarthritis/ Osteoporosis/ Diabetes/ Hyper-mobility Syndromes (e.g. Ehlers-Danlos syndromes)
Skin conditions such as Psoriasis can have some important and relevant effects on your feet/ legs/ tendons and joints etc. Please make us aware of such skin conditions.
Please list your correct medication (if any) here. Please include daily dose, when you started the medication, who prescribed it and for what reason the medication was prescribed. Please either email or bring in written form to the appointment:
This is important as it tells your podiatrist whether we need to re-refer you as part of our treatment plan to such specialist colleagues.
This is important as it tells your podiatrist whether we need to re-refer you as part of our treatment plan to such specialist colleagues.
Anaesthetic, nuts, latex etc. It’s important that we know
This is important as it tells your podiatrist whether we might need to be watchful of potential bone density issues.
Please list the activities that you take part in and advise how many times a week you engage in these activities (include distance of runs etc.)
If not applicable eg: ongoing flat foot - state N/A.
e.g. “in my right heel, worse when I get up in the mornings”)
(e.g. standing/ walking/ running etc.)
(e.g. only when I run/ stand/ everyday etc.)
Please be sure to mention any night pain or rest pain.
(e.g. sharp/ dull/ burning/ throbbing etc.)
Give details of any Back Pain or treatment for Spinal Injuries previously:
This should be the pain score as an average of the last week or so.
This is the worst it has been - feel free to comment when this was and provide any other details that you feel is pertinent.
Any reports can be submitted for with this form.