CHIROPODY

PERSONAL HISTORY

Date :   05 Apr 2004		Birth Date :    ______ / ____ / ____
Name : _________________________________ Address : _________________________________ City : _________________________________ Prov : ____ Postal Code : ________		Home Phone : ( _____ ) _______ Bus. Phone : ( _____ ) ________ Fax Number : ( _____ ) _________ E-mail : ________________________________________
Sex : M F         Age : ____		Height _____ Weight _____
# of Children : ____ Ages : __ /__ /__ /__ /__		Family Doctor :  _________________________________ Doctor's Phone Number:  _________________________
Business/Employer :  _________________________________ Type of Work :  _________________________________

Reason for visit:  __________________________________________________________________

Previous care by a Chiropodist? or Podiatrist? If Yes - Date of last visit? _____ / ____ / ____

Referred to this clinic through: Friend Newspaper Ad Alliance Newsletter Doctor Other

Informed Consent to Chiropodial Care
(REGISTERED CHIROPODIST - Deborah Loundes B.Sc., D.Ch.)

I hereby give permission for the examination and assessment of my feet, as well as give my consent
to perform such diagnostic procedures as may be deemed necessary.
I understand and am informed that, as in all health care, in the practice of Chiropody there are some very
slight risks to treatment. I wish to rely on the Chiropodist to exercise judgment during the course of the
procedures which the Chiropodist feels at the time, based upon the facts then known, is in my best interest.
I have read the above consent. I have also had an opportunity to ask questions about its content, and by
signing below I agree to treatment by the Chiropodist. I intend this consent form to cover the entire course
of treatment for my present condition and for any future condition(s) for which I seek treatment.

 _________________________________Signature (by signin, I consent and agree to the above)



 

Late Cancellation/Missed Appointment Policy
Last minute cancellations and missed appointments are subject to a cancellation charge of $30.00.
Please notify us 24hours in advance if you will be unable to make your appointment.

 Health History:
Please check those items that specifically relate to your medical history. Please answer these
questions carefully as they will be considered in establishing a suitable treatment plan for you:

Head/Ears/Eyes/Nose/Throat
Frequent Headaches	Ringing in Ears	Glasses/Contacts	Recurrent Infections
Previous Head Injury	Difficulty Hearing	Vision Problems	Nose
Fainting Spells	Dizziness	Convulsions/Seizures	Other
Cardiovascular System
High Blood Pressure	Heart Disease	Chest Pain	Poor Circulation
Low Blood Pressure	Heart Attack	Stroke	Bleeding Disorders
Numbness	Angina	Varicose Veins	Leg Cramps
Swollen Ankles	Other
Respiratory System
Shortness of Breath	Smoker	# of cigarettes smoked daily (packs) _____
Asthma	Non-smoker	Have you ever smoked in the past? Yes No For how long? _____
Endocrine System
Diabetes	Thyroid Condition	Addisons Disease	Cushings Syndrome
Other
Musculoskeletal
Joint Pain	Joint Stiffness	Joint Swelling	Limited Joint Movement
Area:  ________________	Area: ________________	Area:________________	Area: ________________
Osteoarthritis	Rheumatoid Arthritis	Osteoporosis	Muscle Weakness
Have you ever broken/fractured any bones? Yes No		Where? ________________
Other
Gastrointestinal/Genitourinary
Poor appetite	Excessive Thirst	Frequent Urination	Kidney/Liver Disease
Rapid Weight Loss	Excessive Hunger	Trouble Urinating	Stomach Ulcers
Other
Childhood Illnesses
Rheumatic Fever	Other
Skin and Nails
Dry/Crackling Skin	Sensitive Skin	Dry/Brittle Nails	Discolored Nails
Moist (sweaty skin)	Rashes/Itching	Fungal Infections	Foot/Leg Ulcers
Slow to Heal	Warts	Bruise Easily	Callous/Corns
Other
Surgery
Foot Surgery	Joint Replacements	Organ transplants	Other
Allergies
Have you ever had allergies? Yes No
Psychological
Depression	Anxiety/Nervousness	Other
Other
Have you ever been hospitalized? Yes No

Please list any medications that you are currently taking:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Have you ever experienced any side effects from local anesthetics, penicillin or other medication?
If so please specify:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Please inform the Chiropodist if you have ever tested HIV positive or have been diagnosed with hepatitis.

I acknowledge that all of the above information is correct. I understand that this information is confidential
and will be used for no other purpose than for the Chiropodists clinical records.

Signature : __________________________________ Date :  __________________________________

 232 South Service Road ~ Oakville, Ontario  L6J 2X5 Canada
tel: 905-845-2291 fax: 905-845-5606
[email protected]