PODIATRY INTAKE FORM

To assist us in determining your patient’s needs and facilitate booking their appointment, please complete this intake form or attach a referral letter / consult form containing the following information and fax or send to our central intake office. PLEASE PRINT CLEARLY. 
					
Date <<Miscellaneous:Date>>	
Patient full name:
<<Patient Demographics:Full Name>>

DOB: <<Patient Demographics:DOB>>	Address:
<<Patient Demographics:Full Address>>

	Patient contact number:
<<Patient Demographics:Phone (Home)>>

Referring Doctor’s name:
<<Doctor:Name>>	Address / practice stamp:
<<Doctor:Address>>	Phone: <<Doctor:Phone>>	

Fax: <<Doctor:Fax>>	

What is the reason for referral / foot pathology?

Please note: Inability to provide self care (nail cutting) in itself is not a reason for referral. Patients will be allocated appointments on the basis of our intake criteria that prioritises patients based on clinical need.	
Please tick if applicable. 
      	
Current foot ulceration	

Past foot ulceration or amputation	

Evidence of Peripheral Arterial Disease	

Evidence of Peripheral Neuropathy 	

Severe foot deformity	

Diabetes (without evidence of foot complications or not yet not assessed)	

Psychiatric illness	

Disability. Give details 

	
End Stage Renal Disease. At which facility do they receive dialysis (if applicable)?  
RPA    or    Concord Hospital	

Patient is a carer	

Patient holds a Pension or Health Care Card 	

Other relevant medical history:
<<Clinical Details:History List>>
	
Current medications: (attach list if there is insufficient space)
<<Clinical Details:Medication List>>
	
Allergies:
<<Clinical Details:Allergies>>	
     Please indicate if you require us to advise you of your patient’s appointment.	
For office use only.    Date received:                                                    Appointment time /date: