Medical History Form

New Patient Registration FormFilling out your medical history form online in the comfort of your own home will save you time at your appointment and helps us ensure that your details are recorded accurately. If you are unable to do this, we ask that you please attend the clinic 10 minutes prior to your appointment time.

Which podiatry centre do you intend to visit?

1) What are your contact details?

Please use exactly the same name and e-mail address as your Patient Registration Form so we can match it to your Medical History Form.

2) What is your main complaint?

3) Do you have a second complaint?

5) Tell us about your medical history:

Have you had any surgeries in the past?

Do you have any allergies?

Tell us about your family's medical history:

6) Are you taking any medications?

7) Have you had any prior podiatry treatment?

8) Do you currently wear orthotics?

9) Do you have diabetes?

10) Tell us about yourself:

11) Is there anything else we should be aware of?