Patient Intake Form
Foot Works by Ashley
Name of individual completing form if not completed by client
First Name
Last Name
Please select all that apply
New Client
Form completed by POA
Form completed by family member
Form completed by foot care nurse
Client's Name
First Name
Last Name
Gender
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the client have any of the following conditions? If yes, please select them:
Cancer
Hypertension
Pacemaker or Defibrillator
Diabetes
Heart Disease
Thyroid Disorder
Epilepsy or Seizures
HIV AIDS
Hepatitis A/B/C
Psoriasis
Eczema
Spinal Cord Injury
Immune Disorder
Blood Clotting Disorder
Skin Disease
Circulation Disorder
Varicose Veins
Kidney Disease
Cognitive Impairment
Dementia
Other
If Other selected, please list below.
Does the client smoke?
Yes
No
Does the client have any known allergies?
Yes
No
If Yes, please specify below.
Does the client or POA have any foot health concerns?
Yes
No
If Yes, please specify below.
Has the client undergone any surgeries?
Yes
No
If Yes, Please list surgery and dates below.
Has the client undergone any amputations?
Yes
No
If Yes, please specify below.
Does the client have a current or past history of foot ulceration or infection?
Yes
No
If Yes, Please specify below.
Please list client's current medications and supplements below
Thank you for completing our patient intake form
We will be in touch soon
Print Form
Submit
Should be Empty: