New Patients

Thank you for your interest in our centre!

Before your first visit, please take the time to prepare yourself as this will ensure that the Chiropodist has all of the needed information to provide the best possible care for you and help relieve any unnecessary anxiety you may be feeling. By reviewing our website, you can educate yourself on your symptoms. As well, take some time to review our staff page and familiarize yourself with our foot care team.

We look forward to your first visit.

Your initial visit includes a full skin and nail assessment, biomechanical exam, diabetic check if needed, and of course treatment for your presenting complaint.
Please bring along any foot orthotics (inserts), off-the-shelf arch supports or other foot devices that you use or have used in the past.
It is also important that we check your footwear. Please bring 2-3 pairs of shoes that you wear the most including dress, casual, athletic shoes or walking shoes.

See you soon!

Online New Patient Form

For your convenience you can fill out our online New Patient form or you can download & print out the PDF version and enter your information before your visit.

Patient Information

" " indicates required fields

First Name

Last Name

Date of Birth

MM slash DD slash YYYY

Address

Primary Phone

Secondary Phone

City

Postal Code

Occupation

Employer

Work Phone

Can We Call You At Work

Yes

Emergency Contact

Emergency Phone

Relationship

Parent/Guardian Names (if child is under 18)

How did you hear about our click to our clinic?

Friend/Family/Colleague

Friend/Family/Colleague Internet Newspaper Health Care Professional Yellow pages Outside sign

Friend/Family/Colleague

Internet

Newspaper

Health Care Professional

Yellow pages

Outside sign

Help us help you!

Your foot problems involve:

Right Foot Only

Left Foot Only

Both Feet

Why are you here today?

Have you sought treatment elsewhere?

Yes

Have you ever been treated for or currently suffer with? (check all that apply)

Back pain

Warts

Heel pain

High arch feet/pain

Corns

Callouses

Bunions

Hammertoes

Gout

Broken foot/leg bones

Flat feet

Ankle injury

Neuroma

Knee pain

Ingrown nails

Childhood foot problems

None

What is your current:

Height

Weight

Shoe Size

In an average day, how much are you on your feet?

20%

40%

60%

80%

100%

What type of footwear do you wear most for work or leisure?

Safety shoe/boot

Athletic

Dress

Sandal

Other

Do you currently use orthotics? (shoe inserts)

Yes

Check any sports or activities you participate in regularly

Walking

Aerobics/Aqua

Fit

Hockey

Racquet Sports

Running

Golf

Soccer

Skiing

Other

None

Other

Please answer the following questions:

Please check any current or past medical conditions:

Diabetes: Type 1 or Type 2

Heart Trouble

Hepatitis

Liver Disease

Urinary Problem

Depression

High Blood Pressure

Cholesterol

Cancer

Shortness of Breath

Stroke

Multiple Sclerosis

Heart Attack

Skin Disorder

Thyroid Problem

HIV/AIDS

Blood Disease

Anxiety

Bone Disease

Arthritis

Epilepsy

Tuberculosis

Stomach/Bowel Trouble

Varicose Veins

Circulation Problems

None

For how long?

Other conditions we should be aware of

Do you have any known allergies to?

Local anesthetics (e.g. Xylocaine, Novocaine)

Yes

Adhesive tape/band-aids

Yes

Latex

Yes

Other

Yes

Allergies Other

Are you slow to heal after cuts?

Yes

Do you bruise easily?

Yes

Are you currently pregnant or nursing?

Yes

Patient Physicians & Medical Specialists:

Family Physician

Family Physician Phone

Please list your current medications (we can photocopy your list)

Please Read

Please read

I agree to the terms

I understand that I am financially responsible for all charges, whether covered by my health insurance plan or not. I authorize the Chiropodist to release all information necessary to secure the benefit of payments. I understand that fees for service are payable at the time of service and insurance reimbursement is my responsibility.

I hereby give consent for examination and treatment by the Chiropodist and/or anyone working in the clinic authorized by the Chiropodist and allow photographs of treatment areas for the purpose of monitoring.

I consent/allow the Chiropodist to send my Physician or health care professional a report regarding my foot exam and treatment plan.

Signature

Date

MM slash DD slash YYYY

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.

Download & Print

Foot Pain? Knee Pain? Take Our Quiz!

01. Do you have pain on the bottom of your foot/feet?

Yes No

02. Do you have pain when you get up in the night or first thing in the morning?

Yes No

03. Do you have heel pain?

Yes No

04. Has anyone told you that you have flat feet?

Yes No

05. Do you have bunions? (bony projections on the sides of your great toes)

Yes No

06. Does your great toe deviate (go toward) your baby toe?

Yes No

07. Do you have calluses on the side of your great toe?

Yes No

08. Have you had an ingrown toenail?

Yes No

09. Do you wear high heels frequently?

Yes No

10. Do you have knee pain?

Yes No

11. Is there pain on the inside or underside of your kneecap?

Yes No

12. Do you hear “crackling” in your knees when you bend?

Yes No

13. Have you had a broken leg or ankle that has left you with unequal leg lengths?

Yes No

14. Are you overweight?

Yes No

15. Do you have back pain?

Yes No

If you answered “yes” to 3 or more of these questions, you may benefit from a prescription foot orthotic. A foot orthotic is a prescription custom-made medical device that goes directly into your shoes.

A prescription foot orthotic helps bring foot muscles and bones back into proper alignment, the same way braces do for teeth. They help restore the normal balance and alignment of your body and bring relief from pain and fatigue. They work so naturally that you will want to wear them as much as possible.

Do you have foot pain?

Call us we can help.

St. Catharines: 905 685-6304

Welland: 905 735-7700