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Full name
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Email
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Phone
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Birthday
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Day
Month
Month
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Address
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Thank you for choosing Jade Tang Podiatry- please tell me what is the nature of your concern?
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Are you diagnosed with any of the following:
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Diabetes
Rheumatoid or inflammatory arthritis
High/low blood pressure
High cholesterol
Heart conditions
Pacemaker
Breathing or chest conditions
Luver disease
Kidney disease
Stroke
Epilepsy or neurological disorder
Mental health condition
Learning difficulties
Drug or alcohol addiction
Bone or joint disease (osteoarthritis/osteoporosis)
Blood clotting condition
Hearing, sight or mobility issues
Not applicable
Other
If you ticked a box please give details.
Please list any medication you take (prescribed or over-the-counter).
Do you smoke or vape?
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Yes
Ex smoker
No
If yes, how much do you smoke or vape
How much alcohol do you consume per week? (a unit is a half pint of lager or small glass of wine)
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I do not drink alcohol
Less than 10 units
10-15 units
15-20 units
20 units
Do you have any allergies
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Yes
No
If you have ticked yes, please give details.
Are you employed
Yes
No
Student
Retired
Please give details of your employment/course/previous employment.
Please list any activities you do and give details.
How did you hear about Jade Tang Podiatry?
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Have you seen a podiatrist before?
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