Heel Pain Telemedicine Visit
  • Date of Birth*
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  • What was your gender at birth?*

  • Format: (000) 000-0000.

  • TERMS OF SERVICE

  • *

  • Advanced Beneficiary Notice

    Patient is solely responsible for paying out-of-pocket the full charge for this visit. This service is not covered under Medicare or Medicaid. Omnia TeleHEALTH will not submit a bill to or request for payment from Medicare and Medicaid or any other payor. 

  • You should NOT use Omnia TeleHEALTH if you are experiencing an emergency. Emergencies include but are not limited to:

    • Severe or unusual chest pain
    • Severe shortness of breath
    • Symptoms of a stroke (such as facial drooping, arm weakness, or speech difficulties)
    • Thoughts of harming yourself or others
  • ARE YOU EXPERIENCING AN EMERGENCY? IF YOU ARE EXPERIENCING AN EMERGENCY, CALL 911 OR GO TO AN EMERGENCY ROOM IMMEDIATELY.*
  • Is your foot/heel pain the result of an injury (such as a strain or fall)?*
  • When did the most recent episode of foot/heel pain begin?*
  • How quickly did your symptoms start?*
  • Which foot is the pain in?*

  • Where is the pain on your foot located? (Select ALL that apply)*

  • There is an area on the foot that can sometimes be tender with plantar fasciitis. It is approximately 2 inches (4 cm) away from the heel, towards the toes, on the bottom of the foot.

  • Does the area under your heel feel tender?*
  • Please rate the severity of your pain on a pain scale, with 0 being no pain and 10 being the worst pain imaginable.*
  • Which sensation(s) do you feel in the foot? (Select ALL that apply)*
  • Does the pain radiate or shoot up your leg?*
  • Is your foot pain the worse when you take the first step of the day after waking up or the first step after sitting for long periods of time?*
  • Does the painful area of your foot have any of the following? (Select ALL that apply)*
  • Have you noticed any color change to the foot?*
  • When you or someone else touches your foot, does the temperature of your feet feel different than other parts of the body?*
  • Are you able to put any weight on the affected foot?*
  • Which of the following causes pain? (Select ALL that apply)
  • Is your pain the worst before, during, or after walking or exercising?*
  • Do any of the following conditions apply to you? (Select ALL that apply)*
  • Do you have any of the following risk factors? (Select ALL that apply)*
  • Have you tried any at-home remedies or treatments for the pain?*
  • Which of the following treatments have you tried? (Select ALL that apply)*
  • Was the treatment(s) effective?*

  • MEDICAL HISTORY

  • Do you have diabetes?*
  • Have you had a hemoglobin A1C taken in the last 6 months?*
  • Please select the HgbA1c range that accurately reflects your result.*
  • Have you been diagnosed with plantar fasciitis by a provider in the past?*
  • Have you been diagnosed with vascular disease by a provider? (Vascular diseases are problems with the arteries or veins that can affect how your blood flows)*
  • Have you been told by a provider to avoid non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen?*
  • Do you have any medication allergies?*
  • Are you currently taking any medications?*
  • Are you pregnant?*
  • Are you breastfeeding?*

  • PHARMACY INFORMATION

    Please choose where you would like your prescription sent
  • Would you like to add any additional information or questions for the provider to see?*

  • My Products*

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