Welcome to our Practice - Hunt Footcare

1 London Foot SpecialistsStratford Foot & Ankle ClinicIngersoll Foot & Ankle Clinic238 Thames Street South,Ingersoll, ON, N5C 2T5 Tel: (519) 485-1750279 Wharncliffe Road NorthSuite 108, London ON, N6H 2C2 Tel: (519) 432 3636502 Huron StreetStratford, ON, N5A 5T7 Tel: 519-271-8834 Patient First Name Male FemaleMiddle NameLast NamePatient Home Street AddressApt#CityPatient Home Phone# [ ]Patient Email Address [please print clearly]Patient OccupationPREFFERED CONTACT METHODPATIENT INFORMATIONHome PhoneCell PhoneWorkEmailEmployer NamePatient HeightDo you currently use orthotics? (shoe inserts)If you have had foot x-rays or diagnostic tests, when were they taken?WeightShoe SizeCell Phone# [ ]Work# [ ]ProvincePostal CodeIf the patient is a minor (Under 18) - provide name of parents or guardianAddress of parents or guardianPhone# [ ]REFERRAL INFORMATIONNameIs this person your:Other Referral Sources [check all that apply and please specify names where indicated]:AddressCell Phone# [ ]We appreciate your referrals!

2 Whom may we thank for referring you to our office?Family DoctorPlease turn over and completeOther SpecialistFamily MemberFriendInternet SearchPhone BookOtherNewspaper AdOur PracticeWebsiteSaw OurSignInsurance PlanOr Website (name)(name)(name)(name)(name) Welcome to our PracticePatient Date of BirthDayMonthYearName of Family PhysicianDate of Last VisitMr. Mrs. Ms. Miss. Dr. Other//Emergency Contact NamePhoneRelationshipPODIATRIC HISTORYMEDICATIONSSURGERIESALLERGIESSIGN ATURE ON FILE AND PERMISSION TO TREATMEDICAL HISTORYHave you ever been to a podiatrist / chiropodist before?Are you curently on Blood Thinners? Yes NoCan you provide a printed list of your medications or list them below:Do you currently use: Cigarettes or Tobacco?If yes, for how long?How many pks/day?Are you currently pregnant or nursing?

3 Alchohol use? Yes No If yes, quantity daily weekly Yes No QuitName of MedicationPlease List All SurgeriesIf other, please explainApproximate DateStrength / Mg Taken how often?When did it begin?Did you receive treatment for this condition?Your foot problem involves: Right Foot Only Left Foot Only Both FeetIf so, what type?Circle the degree of pain you are currently experiencing:Minimal 1 2 3 4 5 6 7 8 9 10 SevereHave you ever had any of the following foot conditions?Please check all that apply:Have ever been treated for any the following conditions?Ankle InstabilityArthritisBack PainBlistersBone SpursBunionsBurning FeetCorns/Calluses foot or toesDiabetic EvaluationFlat FeetFracture (foot/ankle/leg)Fungal Infections(skin/nail)GoutHammertoesHeel PainHip PainInfectionsIngrown ToenailsIntoe - Out toe walkingJoint PainKnee PainLimb Length DiscrepancyNeuromasNumbness or tingling infoot or toesPlantar FasciitisPostural FatiguePronationShin SplintsSprainsSweating/OdorTendonitisTir ed feetUlcersWartsHave you ever had adverse side effects or allergies to.

4 Adhesive TapeAnticoagulantsAnti-InflammatoryMedic ationsAspirinCodeineCortisoneIodineLatex Metal/JewelryNovacainePeanutsPenicillinS eafoodOther AntibioticsOther PainMedicationOtherAcid RefluxAnemiaArthritisAsthmaBleeding DisordersCancerDepressionDiabetesEpileps yFatigueFibromyalgiaHeadachesHeart ConditionHepatitisHigh CholesterolHIV/AidsHypertensionHyperthyr oidismHypothyroidismIrritable Bowel SyndromeKidney ProblemsLiver DiseaseLow Blood PressureNervous DisorderMuscle or Joint PainPeripheral Arterial DiseasePhlebitisPoor CirculationRespiratory DiseaseShortness of BreathSeizure DisordersSkin DisordersStomach UlcersStrokeThyroid ProblemVaricose VeinsYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoYe sNoI hereby allow and consent to examination and treatment by the Chiropodist and/or staff, and allow photographs of treatment areas to be taken for the purposes of understand that I am financially responsible for all charges whether covered by my health insurance plan or not.

5 I understand that service fees are payable at the time service is hereby state that the above information is true and accurate and give my permission to J. Craig Hunt , , PgD., to administer treatment and to perform such operative procedures as may be deemed necessary in the diagnosis and/or treatment of mv foot Signature (or guardian)DateIf other, please explainWHAT IS YOUR MAIN FOOT COMPLAINT TODAY?