New Patient Intake Form

Online Form


    Past Medical History (Please check the appropriate boxes)AnemiaArthritisAutoimmune DiseaseBleeding disordersCancerCellulitisCongestive heart failureDeep vein thrombosisDiabetesFracture historyFungal InfectionsGoutHeart DiseaseHigh cholesterolHigh blood pressureGastrointestinal disordersKidney diseaseLiver diseaseNeuropathyOsteaporosisPeripheral vascular diseasePoor circulationPsoriasisSciatica / Back problemsSeizure disorderStrokeThyroid problemsVaricose veinsWarts



    AllergiesNo know allergiesPenicillinSulfaIodineAdhesive / TapeLocal AnestheticsCortisonAspirin


    Family history
    DiabetesCirculatory ProblemHeart DiseaseGoutHigh Blood Pressure


    Do you smoke?
    NoYes


    Do you drink alcohol?
    NoYes


    Do you exercise regularly?
    NoYes


    PLEASE READ AND SIGN
    The above information is correct to the best of my knowledge. I understand that throughout my treatment at the Kingston Foot and Ankle Clinic I am responsible for notifying the Chiropodist of any and all updates to the information listed above. I give permission to the Kingston Foot and Ankle Clinic to use pictures of my lower extremity as an educational tool in videos and/or pamphlets. I understand that my identity will not be disclosed to the public in these pictures. No personal/medical information will be released to third parties without prior verbal or written consent. I consent to the assessment and/or treatment by the Chiropodist.