Foot and Ankle Care Center Registration Form
Name
First Name
Middle Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
 -
Month
 -
Day
Year
Date
Gender
Male
Female
Other
Do you smoke?
Yes
No
Do you use recreational drugs?
Yes
No
Do you drink alcohol?
Yes
No
Age
Younger than 18
18 or older
Parent Name
First Name
Last Name
Occupation
Occupation, Retired, Stay at home parent, Disability, Not working
Primary Reason for Visit
Which foot/leg?
Left
Right
Other
Problem Area(s)
Big Toe
Toenails
Top of foot
Bottom of foot
Heel
Outside ankle
Inside ankle
Leg
Other
Take or Upload Photo of the Concerned Area
When did the symptoms start?
 -
Month
 -
Day
Year
Date
Please describe the circumstances around the injury or write N/A if unsure.
Severity of Pain
0
1
2
3
4
5
6
7
8
9
10
Mild
Moderate
Severe
Other
Nature of Pain
Aching
Burning
Dull
Itching
Numb
Sharp
Shooting
Tender
Throbbing
Tingling
Other
Course Of Problem
Constant
Worsening
Improving
Intermittent
Morning Pain
Night Pain
End of day pain
Other
Previous Treatments
Pain meds
Inserts
Stretching
Went to ER
None
Other
Other problems you want to discuss
Current Medications
If none, type 'none'
Preferred Pharmacy
Allergies
None
Latex
Metal
Other
Past Medical History
Anesthesia Problems
Asthma
Back Problems
Bleeding Disorder
Blood Clot
Cancer
Dementia
Depression/Anxiety
Diabetic Type 2
Diabetic Type 1
Dialysis
Drugs
Fibromyalgia
Gout
Hepatitus
Heart Attack
Heart Disease
Hypertension
Kidney Disease
Leg Circulation Problem
Liver Disease
Lung Disease
MRSA History
Multiple Sclerosis
Neurological Disorder
Neuropathy
Pace Maker
Parkinson
Rheum Arthritis
Seizures
Stomach Ulcer
Stroke
Thyroid Disease
Artificial Joint
None
Other
Please check if you have had any of the followings recently
Fever
Chills or Night Sweats
Weight Change
Blurred Vision
Partial Blindness
Difficulty Swallowing
Hearing Loss
Mouth or throat problems
Nose or sinus problems
Skin Rash
Skin Infection
Painful Hand Joints
Back or neck pain
Calf Pain
Weakness in arms or legs
Dizziness
Numbness, tingling or burning
Balance problems
Swollen legs
Frequent or painful urination
Pregnant or Breastfeeding
Excessive thirst
Trouble with being too hot/cold
Coughing
Shortness of Breath
Abdominal Pain
Nausea or Vomiting
Diarrhea
Chest pain or pressure
Blood clotting problem
Depression
None
Other
Primary Care Physician
First Name
Last Name
Have you seen PCP in the last 6 months?
Yes
No
Unsure
Family Health History  (immediate family only parents/siblings)
Arthritis
Bunion
Cancer
Diabetes
Flat Feet
Gout
Heart Attack
Stroke
Unsure of family history
None
Other
Type of sport/exercise (If Applicable)
Hours per week
Hour Minutes
Height
Weight
Shoe Size
Additional Notes
Submit
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