Chiropody Initial Intake Form First Name*Last Name*DOB(Month/Day/Year)* Date Format: MM slash DD slash YYYY Sex*MaleFemalePhoneHome*Mobile*WorkAddress*Occupation*Email Address* Emergency ContactName*Relation*Phone*Family Doctor DetailsDo you have a family doctor?*YesNoName*Phone*Doctor Address*How did you hear about us?*GoogleLook LocalDrive byDoctor ReferalFriend/FamilyOtherPlease describe how you heard about us*What is your primary complaint that you are seeking Chiropody for?* Left foot Right foot Knees Hips Back Ankles Briefly explain your concernsDo you have any allergies to the following?* Penicillin Lidocaine Iodine NSAID’s Tape Cortisone Latex Other N/A Please list all*Health History Medical Conditions, please check all that applyHealth History Osteoarthritis Rheumatoid arthritis Stroke/ TIA High Cholesterol Lung/ Breathing disorders Developmental Conditions Fibromyalgia Sudden weight loss Diabetes Type*How long*Health History Liver or Kidney disease Skin Diseases Leg Cramps Gout Epilepsy/ Seizures Chronic Fatigue High or Low blood pressure Heart Disease Poor circulation Thyroid issues Health History Anxiety Depression Digestive Problems Difficulty healing Low immune system Cancer Osteoporosis/ Osteopenia Parkinson Disease Other Please Specify*Medication*I don't take medicationI will provide a list to be photocopied on my visitYes I take medicationList all current medication you are taking*(You may also provide a list to be photocopied by our reception staff)List all Past SurgeriesInternal pins, wires, artificial joints, special equipment?Are you currently Pregnant or Breast feeding?*YesNoNot ApplicableHave you ever been treated for a Communicable disease?*NoYesPlease select below* HIV/ AIDS HEPITITUS TB OTHER N/A Please specify*Do you Smoke?*NoYesHow much*List all Sports/ ActivitiesPayment information: I understand that payments for services are my responsibility after every service has been received. Direct billing to insurance for Chiropody services is not provided. It is your responsibility to submit all receipts to an extended benefit plan on your own. I acknowledge that custom made and ordered devices are not refundable.Cancelation policy: Minimum of 24 hours notice is required to cancel or change an appointment. A charge may be applied if less then this is provided. Should you book an appointment and not attend, you are responsible to pay the entire cost of the appointment.Informed Consent: Footprint Health and Wellness is a multidisciplinary health center where all the practitioners work together to provide optimal and thorough care and treatment. All handling of your information is compliant with existing College of Chiropodist of Ontario guidelines, Provincial and Federal legislation.Is Patient Under the Age of 18?*YesNoPrint Name*Parent/ or Guardian Name*Date* Date Format: MM slash DD slash YYYY Signature*EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.