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 / State / Region ZIP / 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 / State / Region ZIP / Postal Code

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

Please state which language:

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

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

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:

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.

Please upload an images you have of your foot problem.

Drop files here or

Accepted file types: jpg, gif, png, jpeg, Max. file size: 64 MB.

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

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

Please note the Podiatry Service is unable to visit housebound patients who are in residential or care homes. If a patient is able to leave their home for any reason, either assisted or unassisted for visits such as doctor or hospital appointments, shopping, day care or for social reasons, they are NOT eligible for a home visit. Appointments will be offered in the clinic which is most suitable for your needs and as close to home as possible. If a sooner appointment is available this will be offered but might be at an alternative clinic.

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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