Form Page | Gloucestershire Health and Care NHS Foundation Trust

I have read and agree with the above Podiatry Criteria for Treatment *

Yes

Personal Details

Name *

Prefix First Last

Address

Street Address Address Line 2 City County Postal code

Date of Birth: *

If patient is 16 or under

PLEASE NOTE: Any child 16 or under needs to be accompanied by a parent or guardian

Parent/guardian name

Prefix First Last

Parent/guardian address if different from above

Street Address Address Line 2 City County Postal code

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NHS number (if known)

Contact details

Preferred Method of Contact: *

Mobile Phone

Home Phone

Work Phone

Home telephone number

Mobile telephone number

Work telephone number

Email address

Ethnicity: *

Main language spoken *

Do you require an interpreter?

Yes

Work status *

If employed, please state occupation

GP details

GP surgery *

GP address

Street Address Address Line 2 City Post Code

Medical History

Please give details of your medical history and any prescribed medication

0 of 500 max characters

List all diagnosed medical conditions/surgical procedures, e.g. diabetes, amputee, stroke, inflammatory arthritis, osteoarthritis, dementia, mental illness (e.g. depression).

List all prescribed medication

0 of 500 max characters

Do you have any known allergies? *

Yes

What are you allergic to?

Referred by: *

General Practitioner (GP)

District/Practice/Diabetic Nurse

Physiotherapist

Patient (self-referral)

Other health professional - please specify

Any further information you feel is relevant or we should be aware of:

0 of 500 max characters

For example. impaired hearing, wheelchair user, vulnerable adult.

Foot problem details

What foot problems are affecting you? *

Which part of the foot is affected? *

Please give a brief description:

Are you able to provide photographs of your foot problem? *

Yes

Please complete fully and attach a photograph. We conduct an initial triage assessment based on the information you provide and an up-to-date clear photograph is essential for this.

How long have you had the problem for? *

1 Week

Less than 6 Weeks

More than 6 Weeks

Is the foot/problem getting: *

Better

Worse

Staying the Same

Are you able to work/continue with your home activities:? *

Yes

Not Applicable

Does pain from your foot/problem wake you from sleep? *

Yes

Sometimes

At its worst, how painful is the foot/problem, with 1 being 'no pain' and 10 being 'extreme'?

Have you attended the Podiatry Service for this condition before? *

Yes - Less than 1 year

Yes - More than 1 year

Are you seeing any other health professional in relation to your foot/problem? *

Yes

If so who have you seen?

Physiotherapist

Musculo-Skeletal Therapist (MSKCAT)

Orthopaedic Consultant

Orthotist

Other - Please Specify

What treatment have you received for the problem?

For this foot/problem have you had:

X-rays

Scan

Ultra Sound

MRI

Other - Please Specify

Mobility Details

Mobility - Please select relevant response: *

Walk unaided

Use sticks

Use frame

Wheelchair user

Housebound

PLEASE NOTE: YOU WILL BE DISCHARGED FROM THE SERVICE AND YOUR GP NOTIFIED IF YOU FAIL TO ATTEND YOUR FIRST APPOINTMENT

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Personal Details

If patient is 16 or under

Contact details

GP details

Medical History

Foot problem details

Mobility Details

Home visits can only be referred by a health professional or GP

PLEASE NOTE: YOU WILL BE DISCHARGED FROM THE SERVICE AND YOUR GP NOTIFIED IF YOU FAIL TO ATTEND YOUR FIRST APPOINTMENT