Classic form

Podiatry intake form that asks about diabetes first

Two answers decide how a podiatry appointment is run before the podiatrist has seen a foot: whether the patient has diabetes, and whether the circulation and nerve supply are intact. This fifteen field intake form asks both in the first health block, then collects the footwear, the standing hours and the orthotics history that explain the rest.

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New patient form, Sole Care Podiatry

Please complete before your first appointment, and bring the shoes you wear most days. Not your good shoes, the ones you actually stand in.

About you

Your feet

Health that changes foot care

The next three questions decide how the appointment is run. Diabetes and reduced circulation change how nails and hard skin are cut, how a wound is dressed and how often a foot needs checking. Your answers are health information, read by your podiatrist and kept in the practice record.

Shoes, activity and orthotics

Funding and referral

A GP chronic disease management plan referral, a Veterans Affairs referral, or an x ray or ultrasound report. A phone photo of the printed page is fine. Images or PDF, up to 10 MB each.

Consent

By signing you confirm the information is accurate and consent to assessment and treatment, which may include cutting nails and hard skin, debriding a corn, padding, strapping and taking a cast or scan for orthotics. Any procedure is explained before it is done and can be declined. Fees are payable on the day and your health fund card is processed at the desk rather than recorded here.

Every field, and what it collects

The complete field list, in the order respondents meet it.

About you

Your nameNameRequired
Date of birthDateRequired
MobileShort textRequired
EmailShort textRequired

Your feet

What is going on with your feet, and how long for?Long textRequired

Health that changes foot care

Do you have diabetes?Single choiceRequired
Options: No · Type 1 · Type 2, managed with diet or tablets · Type 2, on insulin · Pre diabetes or impaired glucose · Not sure
Do you notice any of these in your feet or legs?Multiple choiceRequired
Options: Numbness, pins and needles or burning · Cramping in the calves when walking, easing with rest · Feet that are cold to touch or look pale · Swelling in the ankles by the end of the day · Cuts and grazes that take a long time to heal · Colour change in a toe · Varicose veins · Nothing like this
Other conditions that matter for foot careMultiple choiceRequired
Options: Rheumatoid or other inflammatory arthritis · Osteoarthritis · Peripheral neuropathy already diagnosed · Kidney disease or dialysis · Blood thinning medication · Immune system suppressed · Previous foot or ankle surgery · A foot ulcer, now or in the past · Chemotherapy in the last two years · None of these
Medications you takeLong text

Shoes, activity and orthotics

What do you wear on your feet most days?DropdownRequired
Options: Lace up runners · Slip on sneakers · Steel cap work boots · Leather work shoes or dress shoes · Heels above four centimetres · Ballet flats · Thongs or slides · Sandals with a strap · Boots, ankle or knee height · Bare feet most of the day
How much are you on your feet?Single choiceRequired
Options: Seated most of the day · Standing or walking a few hours a day · On my feet all day at work · On my feet all day, on hard floors or concrete · Running or sport three or more times a week
Have you worn orthotics before?Single choiceRequired
Options: Never · Off the shelf inserts from a pharmacy · Custom made, currently wearing them · Custom made, gave up on them · Made for me but never collected

Funding and referral

How is this appointment being paid for?Single choiceRequired
Options: Private, claiming on a health fund · Private, no rebate · GP chronic disease management plan, referral in hand · Department of Veterans Affairs · NDIS plan · Workers compensation claim · Not sure, please check at the desk
Referral, care plan or recent imaging reportFile upload
A GP chronic disease management plan referral, a Veterans Affairs referral, or an x ray or ultrasound report. A phone photo of the printed page is fine. Images or PDF, up to 10 MB each.

Consent

SignatureSignatureRequired

What each block of this form collects

The identity block is four fields, then one open question about the feet, and then the block that changes the appointment. Diabetes is asked as six options rather than yes or no, because type 2 managed on tablets and type 2 on insulin are different risk pictures and not sure is an honest answer that gets checked at reception. The circulation and nerve list asks about the specific things a patient can notice without being told to look: numbness, calf cramping that eases with rest, feet cold to touch, swelling by evening, cuts that take too long. The third block is about load and habit rather than disease. What is on the feet most days, how many hours they carry weight, and what has been tried in the way of orthotics, including the two honest failure answers that most forms never offer.

The Australian pieces on this form

The funding radio names the real Australian pathways: private with a health fund rebate, private with none, a GP chronic disease management plan with the referral in hand, the Department of Veterans Affairs, an NDIS plan and a workers compensation claim. The chronic disease pathway is the one podiatry sees most, because a patient with a chronic condition such as diabetes can be referred by a GP for a limited number of allied health services in a calendar year, and the practice has to hold the referral before it can claim. That is why the upload sits directly under the funding question and why the thank you screen still asks for the original paperwork at the desk. Podiatrists here are registered with the national board, and no Medicare or health fund membership number is collected in the form at all.

How to adapt this form

A high risk foot clinic promotes the diabetes block into its own page and adds the date of the last foot check, the most recent glucose result and a question about whether the patient can see and reach their own feet, since that single question decides whether self care advice is realistic. A sports podiatry practice replaces the footwear dropdown with a training shoe and surface pair, weekly kilometres and a recent change question, because in that setting the cause is usually a change in load. A residential aged care service drops the funding radio for a facility and room block and adds a next of kin field, since consent and billing both run through somebody else.

What makes this form work

Diabetes is six options, not a yes or no

Type 1, type 2 on tablets, type 2 on insulin, pre diabetes and not sure sit beside no. Those are five different risk pictures for the same foot, and a yes or no question throws the difference away at the exact moment it matters most.

Circulation is asked in symptoms a patient can notice

Cramping in the calves when walking that eases with rest, feet cold to touch, cuts that heal slowly, colour change in a toe. Nobody knows whether their arterial supply is reduced, but everybody knows whether their calves cramp on the way to the shops.

The orthotics question offers two ways to have failed

Gave up on them, and made for me but never collected. Both answers are common, both are embarrassing to volunteer, and both change what the podiatrist recommends. Printing them as options is what makes them gettable.

Questions people ask

Why does a podiatrist ask about diabetes before anything else?

Because it changes the appointment. Reduced sensation means a patient cannot feel a cut being made, and reduced healing means a small nick matters more than it would otherwise. Knowing before the appointment lets the podiatrist plan a neurovascular assessment into the time rather than discovering the need for one halfway through.

What is calf cramping that eases with rest a sign of?

It is the classic description of reduced arterial supply to the legs, and it is the one circulation symptom patients reliably recognise in themselves. Putting it on the checklist in those words, rather than asking about peripheral arterial disease, is why the answer arrives on the form instead of in the room.

Why does the form ask which shoes are worn most days?

Because the everyday pair causes the problem and the good pair gets described. Ten options cover what people actually stand in, and the welcome screen asks the patient to bring the real pair, since wear on a worn sole shows the loading pattern faster than any question does.

What is the point of asking about orthotics that were never collected?

It is the most useful answer in that question. A patient who was cast, charged and never came back has a reason, and it is usually cost, comfort or scepticism. Knowing it before the appointment stops a podiatrist recommending the same thing again and opens the conversation that should have happened the first time.

What can be uploaded to the referral field?

A GP chronic disease management plan referral, a Veterans Affairs referral, or an x ray or ultrasound report. The upload accepts images or PDF, up to three files at 10 MB each, which covers a phone photo of a printed referral plus two reports. Those are the only two file kinds a form upload allows.

Does the practice collect a Medicare or health fund number?

Not on this form. The consent paragraph says the health fund card is processed at the desk, and any Medicare detail needed for a chronic disease claim is taken from the original referral at reception. Collecting identifiers in person rather than in a web form is both safer and shorter, and it removes two fields from the intake.

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