Plantar Wart Physical Exam Form
Please complete all fields for a comprehensive plantar wart physical exam intake.
Patient Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Exam Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Affected Foot/Toe Location
*
Please Select
Left Foot
Right Foot
Left Big Toe
Right Big Toe
Other Toe
Heel
Ball of Foot
Other
Symptom Duration
*
Please Select
Less than 1 week
1-4 weeks
1-3 months
More than 3 months
Pain Level
*
No pain
0
1
2
3
4
5
6
7
8
9
Severe pain
10
0 is No pain, 10 is Severe pain
Prior Treatments Tried
Over-the-counter medication
Cryotherapy (freezing)
Salicylic acid
Duct tape
None
Other
Visible Wart Characteristics
Raised lesion
Rough surface
Black dots (thrombosed capillaries)
Callused skin
Tender to touch
Other
Mobility or Activity Impact
No impact
Mild interference
Moderate interference
Severe interference
Other
Additional Notes or Clinician Observations
Submit Exam
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