Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Podiatry Intake Form
Your information
Full Name *
Date of Birth
____ / ____ / ________
Phone Number
Email Address
Primary Foot/Ankle Concern
Foot Pain Location & Severity
Foot & Ankle Symptom Checklist
Diabetic Foot Screening
Additional details
Footwear & Orthotics History
Activity Level & Gait Concerns
Prior Podiatric Procedures
Current Medications
| Medication | Dose | How often |
|---|---|---|
Diabetes & Vascular History
Insurance Information
Carrier
Member ID
Group number
Subscriber name
Consent & Signature
Date
Podiatry Intake Form template from formisoft.com. formisoft.com/intake-templates/podiatry-intake