Heel Pain Assessment Survey
Help us understand your heel pain to assist with diagnosis and treatment.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
Gender
*
Male
Female
Other
How long have you been experiencing heel pain?
*
Please Select
Less than 1 week
1-4 weeks
1-3 months
More than 3 months
Please rate your average heel pain over the past week.
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain possible
10
0 is No pain, 10 is Worst pain possible
Describe the nature of your heel pain.
*
Sharp
Dull/aching
Burning
Throbbing
Stabbing
Other
When do you experience the most heel pain? (Select all that apply)
*
First steps in the morning
After standing for long periods
After exercise
At rest
Other
Please indicate how heel pain affects your daily activities.
*
Rows
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable to Perform
Walking
1
2
3
4
5
Standing
6
7
8
9
10
Climbing stairs
11
12
13
14
15
Exercising
16
17
18
19
20
Have you tried any treatments for your heel pain?
Rest
Ice/heat application
Pain medication
Physical therapy
Orthotics/shoe inserts
Other
Do you have any of the following medical conditions? (Select all that apply)
Diabetes
Arthritis
History of foot/ankle injury
None of the above
Other
Is there anything else you would like to share about your heel pain?
Submit Assessment
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