Patient Questionnaire | Payment Plan | Warranty | Gift Certificate
Thank you for taking a few minutes to complete this form. Your information will assist us in providing optimal care.
Patient's Name
Street Address
City
Postal Code
Telephone Number
Who referred you to this clinic? Physician
or Friend
If not referred, how did you hear about Footprint's Orthotics?
Do you or a family member have an extended medical plan? Yes No
Have you worn orthotics before? Yes No
Has there been a history of foot problems in your family Yes No
Have your children or other family members been screened for orthotics? Yes No
To allow us a better understanding of your physical activities, please complete the following. Check one or more.
Work Related Activities Standing   Walking
Bending    Lifting
Recreational Related Activities Running   Walking  
Tennis    Golf
List other sporting activities
Can you walk more than one kilometer comfortably? Yes No
Can you run, walk, or do another related activity comfortably? Yes No
Do your legs or feet feel tired at the end of the day? Yes No
Do you have pain in the bottom of your feet, first thing in the morning? Yes No
Do you experience knee pain, when walking or running? Yes No
Do you experience hip or lower back pain? Yes No
Have you ever missed any days from work as a result of these problems? Yes No
Have these conditions interfered with your work or recreational activities? Yes No
Primary Complaint:
Please contact me to schedule an appointment. Yes No
 
Call for an appointment at 604-534-2004

4041-200th Street
Langley, BC V3A 1K8
Canada

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