Date of Birth:
How did you hear about our clinic?
Please answer the following foot questions:
Do your foot problems involve:
Why are you here today? Please explain your current problem(s):
Have you had previous treatment for this problem?
Who did you see?
Have you ever had orthotics/shoe inserts?
Have you ever been treated for: (Please check all that apply)
Have you ever had foot x-rays taken?
What is your current:
Do you or have you ever been treated for: (Please check all that apply)
Other general medical conditions:
Are you pregnant or nursing?
Please list previous surgeries with dates:
Please list your current medications:
Do you have any known allergies to:
Local Anasthetics (eg. Xylocaine, novocaine)
McRae Foot Health Centre will treat your personal information with respect. Our privacy protocols comply with privacy legislation, College of Chiropodists of Ontario standards and the law. Be assured that everyone in our office is committed to ensuring that you receive the best quality foot care.
I hereby allow and consent to examination and treatment by the Chiropodist.
I hereby allow myself to be photographed at the discretion of the Chiropodist.
I consent the Chiropodist to contact my physician/healthcare provider to exchange information relating to my treatment.
I understand that I am financially responsible for all charges whether covered by my health insurance plan or not. I understand that service fees are payable at the time of service.