Patient Information

Fields marked with * is required

Todays Date*

FirstName*

MiddleName

LastName*

NICKNAME

DOB*

Gender

Male

Female

Mobile phone*

Home phone*

Email*

MAILING ADDRESS*

CITY*

STATE*

ZIP*

SS*

PODIATRIST*

PCP*

REFERRED BY

JOBACTIVITIES*

ANY PATIENT SPECIFIC NOTE

Patient stated diagnosis by Primary Care Physician

Have you ever been diagnosed by a doctor for a foot related medical condition?

Yes

No

Systemic Disease (X)

Arthritis A

RhA

Diabetes:

Type 1

Type 2

Peripheral Neuropathy

Poor Circ

(Right)

(Left)

How long has PT been diabetic?

Protective Sensation

Intact

Decreased

Diminished

Ulcer Grade:

0-None

1-Superficial

2-Tendon or bone depth

3-Abscessoste/omyelitis

4&5-Gangrene

Goals:

Pain relief

Improves foot/ankle alignment

Increase stability

Increase gait

Other

Which?

Plan:

Impression taken

Inserts fabricated and fit to patient

Patient instructed to call with any problems

Patient has tried on sample orthotics and has agreed to

Patient initials

Date

E-Signature

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