Foot and Ankle Care Center Registration Form

Collect complete clinical intake information from new podiatry patients: reason for visit, symptoms, prior treatments, medication and family history. Patients can even attach a photo of the affected area before their appointment.

Use this template

Name

Nombre

Apellido

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Date of Birth

Gender

Female Male Prefer not to say

Do you smoke?

Yes No Occasionally

Do you use recreational drugs?

Yes No Prefer not to say

Do you drink alcohol?

Yes No Occasionally

Parent Name

Nombre

Apellido

Occupation

Primary Reason for Visit

Which foot/leg?

When did the symptoms start?

Describe the circumstances of the injury or write N/A if unsure.

Severity of Pain

Mild Moderate Severe Unbearable

Course of Problem

Improving Worsening Unchanged Comes and goes

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