Client Forms

Client Checklist

Please download our

Diabetes Information

Schedule online. It's easy, fast and secure.

PRE-APPOINTMENT FORMS

How to use these Pre-Appointment Forms

These forms are intended to help you and your podiatrist understand both the treatment you receive

and to manage your post treatment self-care programme

Downloadable Client Forms

Adaptable Individual & Monitored

Initial Assessment Questionnaire

10 mins before appointment

 

Please download and print our initial assessment questionnaire which will comprise your confidential medical history file, This will help you help Yourpodiatrist to assess, diagnose (where appropriate) and treat your feet according to your individual needs. Thank you

 

Timeliness

 

Please arrive 5-10 minutes early for your appointment to allow for a medical form to be completed.

 

Medication

Please bring along a list of any prescription medicines you currently take. Your initial consultation and treatment may take a little longer, please allow 30-40 minutes.

 New Patients

New patients will be assessed according to their medical and podiatric need using priority criteria. An appropriate treatment plan will be created according to the patient’s medical and podiatric needs which will be agreed upon by the podiatrist and the client. If required appropriate follow up care will be arranged by the podiatrist.

All new hospital referrals are triaged and assessed based on the information entered on the application form.

 

It is important to make sure all details about your medical conditions and the medication you are taking are completed correctly.

Foot Pain Assessments

Foot pain assessments are available in clinic, please wear loose fitting trousers or bring shorts to change into. You can book an appointment by contacting Jo on 07975 828 976 who will be happy to make arrangements for you.

Are you diabetic?

 Chronic Pain in Foot Questionnaire

Complete the Chronic Pain Questionnaire to find out if you can be free

from a previously unknown, common source of chronic musculoskeletal pain  

 

        (This questionnaire is not a replacement for a thorough medical examination 

                               nor should it serve as a tool for making a medical diagnosis.)
 


____  Do I have calluses on the bottom of my feet?                                Y       N


____  Do I have bunions?                                                                              Y       N       

____  Do I have a head forward position? (See Fig.1)                                 Y       N

____  Do I have bad posture?                                                                       Y       N

____  Do I have scoliosis (severely curved spine)?                                    Y       N

____  Was I clumsy or awkward as a child?                                                Y       N

____  Are my shoulders rounded?                                                               Y       N

____  Do I have crooked teeth?                                                                   Y       N

____  Am I a vegan                                                                                       Y       N

____  Do I have poor balance?                                                                     Y       N

____  Do I have a tipped pelvis (swayback)?                                               Y       N

____  When I walk with someone side by side,                                          Y       N

          do I have a tendency to bump into them?

____  Has my doctor told me that I have one leg shorter than the other? 

 

                                                                                                                         Y       N

____  Do I have pains that come and go in different joints?                      Y       N

____  Do I prefer to walk barefoot around the house?                              Y       N

____  Do I have tight and/or stiff muscles?                                                 Y       N

____  Have I seen multiple healthcare practitioners in an effort to

resolve my chronic musculoskeletal pain?                                 Y       N

____  Are the heels on my oldest pair of shoes worn unevenly?              Y       N

 (See Fig.2 )        


Thank you for completing

this CHRONIC PAIN symptom description form

Results:

if you have more than eight yes answers

we would advise you to contact us now for an appointment 

with Soft Soles Podiatry

Mr Michael Franklin

Chief Podiatrist

07 5636 56666

 


Please copy and print off and bring to your appointment       

        Figure 2 - unevenly worn heels             Figure 1 - forward head position


If you answered Yes to 8 or more of the above questions, your chronic musculoskeletal pain can likely be eliminated by Rothbart Proprioceptive Therapy. 

Understanding the Symptoms of Your Chronic Pain Problems.

To learn how Rothbart Proprioceptive Therapy works and what is involved, go to the Rothbart Therapy page and/or the Patient's Commitment pages.

If you are ready to take the next step towards freedom from chronic pain, go to the Schedule an Initial Phone Consultation page.

Figure 1 - forward head position

Figure 2 - unevenly worn heels 

Note - Look for unevenly worn heels in shoes

with soft rubber or foam- like heels.

Hard rubber heels may not show this wear pattern.  

Please download our Customer Survey Form

Payment terms?

Payment is made after each consultation either by cheque, cash, or major debit/credit card.

If you have private medical insurance we can provide you with a receipt so that funds can be claimed back by you. As previously mentioned, some insurance policies require your GP to authorise treatment. Please contact your insurance provider prior to arranging your appointment to check your policy details.

​Cancellation policy?

Please be aware that we reserve the right to make a charge of £20 per 30 minute appointment for failed appointments and cancellations within 24 hours of your appointment.

Health plans we accept:

We are happy to help guide you through this process to insure that you get the best treatment, for your plan. You may well be covered for treatments that you did not expect, so please mention your insurer when you call.

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Not covered by any of these plans? Contact us and we will find the best solution to suit you.