Plantar Fasciitis Evaluation Form
Use this form to record foot pain symptoms, history, and treatment details for a plantar fasciitis evaluation.
Patient Information
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Contact Method
*
Phone
Email
Either
Plantar Fasciitis Evaluation
Primary Foot Affected
*
Left
Right
Both
Pain Location
*
Heel
Arch
Bottom of foot
Inner heel
Outer heel
Other
Pain Severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Pain Timing
*
First steps in the morning
After prolonged standing
After exercise
Constant
Other
Symptom Duration
*
Please Select
Less than 2 weeks
2–6 weeks
6 weeks–3 months
More than 3 months
Other
Impact on Daily Activities
*
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
Treatment and Follow-up
Prior treatments tried
*
Rest
Stretching
Ice
Orthotics
Pain relievers
Physical therapy
None
Current medications or therapies
Preferred next step
*
Schedule evaluation
Receive home-care guidance
Discuss treatment options
Submit
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