New Patient Intake FormPlease download our intake form. Online Form Patient Name (required) Address (required) Birthday (required) Reason for Today's Visit (required) Family Physician (required) Occupation Your Email (required) 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 Please specify for if you have checked off the following: Autoimmune disease, cancer, diabetes, and fracture history Current Medication AllergiesNo know allergiesPenicillinSulfaIodineAdhesive / TapeLocal AnestheticsCortisonAspirin Other Allergies Please list any surgeries or hospitalizations Family history DiabetesCirculatory ProblemHeart DiseaseGoutHigh Blood Pressure Do you smoke? NoYes if yes, how long? 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.