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New Patient Form

Patient Intake Form

Please fill out the form below and Click on Submit Form once completed.

New Patient Information Form

First Name:

Last Name:

Initial:

Birthdate:

Age:

Gender:

Male

Female

Unspecified

Other

Address:

City:

Postal Code:

Home Phone:

Cell:

Work:

Email:

What is your preferred method of contact :

Home Phone

Work

Cell

Employer:

Occupation:

Emergency Contact Name:

Phone:

Relationship:

Family Physician / NP:

Phone :

Extended Health Benefits:

Yes

No

If Yes, please indicate your Insurance Provider:

Are you covered by any of the following?

Veteran’s Affair’s Canada

Ontario Disability Support Program

Ontario Works

Non-Insured Health Benefits (First Nations/Inuit)

WSIB

Whom may we thank for referring you to our office:

How did you hear about us?

Word of Mouth

Internet

Television

Phone Book

Physician

Other

PODIATRIC HISTORY

Have you had any major foot or leg injuries?

Yes

No

Do you get numbness in your feet or toes?

Yes

No

Do you get tingling in your feet or toes?

Yes

No

Do you get foot or leg cramps?

Yes

No

Did your parents have foot problems?

Yes

No

Do your feet perspire excessively?

Yes

No

Are your feet excessively dry?

Yes

No

Do your feet have a strong odour?

Yes

No

Do you treat your own feet or cut your own callouses?

Yes

No

Do you find your feet to be hot, cold or normal?

Hot

Cold

Normal

Do you walk toe in, toe out or normal?

Toe in

Toe out

Normal

Have you had foot care by another Chiropodist / Foot Specialist?

Yes

No

If yes, by whom?

When?

Have you had previous Foot x-rays?

Yes

No

If yes, where?

When?

Briefly describe your current foot problems:

Shoe Size:

What footwear do you most commonly wear?

MEDICAL HISTORY

MAJOR DISEASE

Heart

Arrhythmia

Heart Attack

Diabetes

Stroke

Heart Murmur

High Blood Pressure

Chest pain

Mitral Valve Prolapse

RESPIRATORY

Asthma

Bronchitis

Frequent Colds

ARTHRITIS

Osteoarthritis

Rheumatoid

Gout

GASTROINTESTINAL

Acid Reflux

Bowel Disorders

Crohn's Disease

VASCULAR

Anemia

Bleeding Disorders

Blood Clots

Sickle Cell

Swelling Phlebitis

Vein Problems

Poor Circulation

Leg Ulcerations

Spider Veins

Transfusions

Night Cramps

Varicose Veins

Leg Pain When Walking

MISC

Anxiety

Depression

Alcohol Dependence

Drug Dependence

Psychiatric Condition

Other Illnesses

HAVE YOU EXPERIENCED ADVERSE SIDE EFFECTS FROM ANY OF THE FOLLOWING?

Aspirin/ASA

Neomycin/Polysporin

Steroids

Erythromycin

Novocain/Freezing

Sulfa Drugs

Latex

Penicillin

Tape allergy

Codeine

Iodine/Shellfish

Other:

Have you ever tested positive for Hepatitis or HIV?

Yes

No

Are you currently pregnant?

Yes

No

Do you smoke tobacco?

Yes

No

Alcohol consumption:

None

1-2 week

1-2 day

more than 2 day

Date of last doctor’s visit:

Height:

Weight:

PLEASE LIST ALL CURRENT MEDICATIONS: (If multiple medications please bring list from Pharmacy)

Which Pharmacy do you use?

Thank you for submitting your patient intake form!

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Business Hours

Mon - Fri: Appointment Only
Sat - Sun: Closed

If preferred, our New Patient Form can also be downloaded and printed by clicking the button below.

DOWNLOAD NEW PATIENT FORM Call Us

Put your feet in good hands.

Get Directions Patient Intake Form (Printable)

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AFFILIATIONS

CONTACT

(P) 705-759-8525
(F) 705-759-1749
reception@simardfootclinic.com
765 Queen St E #201,
Sault Ste. Marie, ON
P6A 2A8
Located in the Superior Health Centre
(old PUC building)

© 2022 Simard Foot & Ankle Clinic
Designed By Jeronamo Solutions

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