Patient Questionnaire 

New patient questionnaire

Use this form to provide us your personal information and specific Podiatric history. This form is essential in order to help us to help you.
  • SECTION 1: General Questions

    3D Footprint Podiatrists need as much information as possible about you to support our clinical partners in personalising your treatment. This initial information is vital to give us an insight into your condition. The foot and limb are affected by all systems in the body. The more information we have about your health the better.
  • 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.)
  • Section 2. Specific Questions about your Podiatric Problem

    Please give details as this helps your Podiatry team with your treatment.
  • 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.
  • Drop files here or
    Accepted file types: jpg, gif, png, pdf.

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