Podiatry Intake Form

The Podiatry Intake Form is purpose-built for podiatric medicine practices, capturing the detailed foot and ankle history that podiatrists need for accurate diagnosis and treatment planning. This template collects patient demographics alongside a comprehensive lower extremity assessment covering foot pain (location, onset, aggravating factors), ankle instability, bunion and hammertoe symptoms, plantar fasciitis screening, ingrown toenail history, fungal nail infections, warts, callus and corn patterns, and neuroma symptoms. The diabetic foot screening section captures neuropathy symptoms, vascular status, prior foot ulcer history, and current foot care regimen.

Designed for general podiatry, podiatric surgery, sports podiatry, diabetic foot care, and wound care practices, this form includes sections for gait and biomechanical concerns, footwear assessment (type, fit, orthotics use), activity level and sport participation, prior podiatric procedures (bunionectomy, hammertoe correction, neuroma excision, nail surgery, fracture repair), imaging history (X-ray, MRI, ultrasound), and a medication list covering topical antifungals, orthotics, diabetic medications, and blood thinners. The occupational section captures standing and walking demands relevant to treatment planning.

All fields are HIPAA-compliant and structured for the podiatric evaluation workflow. Patients document their foot and ankle symptoms, diabetic foot care status, and footwear history before the visit, enabling the podiatrist to focus the examination on the areas of concern and determine whether diagnostic imaging, custom orthotics, or surgical intervention may be indicated.