Podiatry Patient Intake Form

Podiatry Patient Intake Form — Form Fields

This healthcare template includes 9 fields. Collect health history and foot or ankle concerns for new podiatry patients. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Email Address (email, required)
• Date of Birth (text, required)
• Phone Number (text, required)
• Primary Concern (dropdown selection, required) — options: Heel pain, Toenail issue, Bunion, Hammertoe, Plantar wart, Arch pain, Diabetic foot care, Sports injury, Other
• Describe your symptoms (long text, required)
• How long have you had this concern? (multiple choice, required) — options: Less than 2 weeks, 2-8 weeks, 3-12 months, Over 1 year
• Relevant Medical History (checkboxes, optional) — options: Diabetes, Peripheral neuropathy, Arthritis, Circulation problems, Previous foot surgery, None
• Do you use orthotics or special footwear? (multiple choice, required) — options: Yes, No