Please note: items marked * indicate mandatory fields. Title * - Select -MrMrsMissMsDr First name * Last name * Date of Birth * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year19211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Medical information Are you diabetic? * Yes No Are you a smoker? * Yes No Please be aware that smoking has serious adverse effects on your health and puts you at a much higher risk of wound and bone healing problems after surgery. Medical History * List any of the following that you currently have, or have ever had. Anxiety, depression, other psychiatric issues Asthma Deep vein thrombosis Gastric ulcers Heart attack Lap Band Surgery Postoperative infections Pulmonary embolism Stent or Pacemaker inserted Stroke None of the above Current Medications * Aspirin Assasantin Clopidogrel Insulin Plavix Prednisolone Methotrexate Warfarin None of the above Social Circumstance Do you live alone? * Yes No Is there anyone able to assist you after surgery? * Yes No Other Party * Partner / Spouse Children Parent Friend / Housemate Do you live in a house with multiple stories / stairs between areas? * Yes No Employment Status * Employed Not Employed Common postures while working * Seated Standing Walking Do you drive? * Yes No Details of Medical Problem General area of problem * Achilles tendon Ankle Bunion Foot Heel Toe(s) Which foot is affected? * Left Right Which foot surface is affected? * Inner Outer Top Bottom Approximate date problem started * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year19211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Symptoms of problem * Clicking or grinding Instability or giving way Locking or catching Numbness or tingling Pain Stiffness Swelling Weakness Recent status of problem * Getting better Getting worse Staying the same Varies over time When do you have the problem? * Resting Walking Running Standing Sport Morning Day Night All the time Pain level * None Mild Moderate Severe Things that make the problem worse? * Uneven ground Standing Walking on a level surface Walking up stairs or hills Walking down stairs or hills Walking sideways along a slope Sport Shoes Long days on your feet Other Description of other thing that makes the problem worse * Things that make the problem better? * Rest Orthotics Anti-inflammatories Painkillers Other Description of other thing that makes the problem better * Activity level * Unrestricted Can run but at reduced distance / speed Unable to run Unable to walk long distances Unable to walk short distances Maximum walking distance and time * Activities mainly affected * Daily mobility Driving Home duties Sport Work Other Description of other activity affected * Most comfortable footwear * Bare feet Boots Runners Soft spacious shoes Solid shoes Most uncomfortable footwear * Bare feet Boots High heels Tight shoes Previous Treatments * Surgery Dressings Local padding Orthotics Physiotherapy Osteopathy Acupuncture Cortisone Injections Anti-inflammatories Painkillers Other Description of other treatment * Submit
