Telehealth Podiatry Pre-Consultation Form - N8Health | Bendigo, Echuca, Kyabram & Deniliquin Chiropractor, Podiatry & Massage

n8 Podiatry Pre-Consultation Form

Patient Details

First Name *

Last Name *

Date of Birth (dd/mm/yyyy) *

Email *

Address *

Suburb *

Postcode *

Best contact number

Occupation

How did you hear about us?

If friend, please provide their name so we can thank them

Do you suffer from any medical conditions? (to select more than 1 condition hold the Ctrl key and click each condition)

Other medical conditions:

Are you on any Medications?

Do you have any allergies?

About you

What brings you to have a telehealth consult?

How long have you been experiencing this problem? (days, weeks, months, years)

Has it been getting better or worse or no change?

Have you suffered this before?

Where is your pain?

How long have you felt your pain?

When do you feel your pain?

Can you remember if anything caused your pain? Explain if so

Does anything make the pain go away?

Have you taken any medication for your pain?

Footwear

What shoes do you normally wear?

How long have you had your usual pair of shoes?

Are you barefoot around the house?

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