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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
Please arrive 5-10 minutes early for your appointment to allow for a medical form to be completed.
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 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?
____ 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
if you have more than eight yes answers
we would advise you to contact us now for an appointment
with Soft Soles Podiatry
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.
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.
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.
Not covered by any of these plans? Contact us and we will find the best solution to suit you.