Request for NHS podiatry services /
Please complete all sections of this form and return it to us via post, email or fax, using the contact details
at the end of this form.Once received we will contact you and if appropriate we will make an appointment for your foot health needs to be assessed.
Mr / Mrs / Miss / Ms / Master / Telephone numbers:
Surname: / Mobile:
First name(s) / Home:
Work:
Home address:
Postcode: / GP:
Surgery address:
Postcode:
Date of birth: / NHS number:
Next of kin: / Contact number:
Have you received treatment from this service in the past? / YES / NO
Do you need an interpreter? / YES / NO / If yes, what language
do you speak?
SECTION 1: MEDICAL HISTORY (please tick those that apply) / For office use
Diabetes mellitus / Neuropathy
Immunosuppression / Severe circulatory disorder
Rheumatoid arthritis / Respiratory disorder
Stroke / Neurological
Heart conditions / Mild circulatory disorder
Osteoporosis / Mental / learning disability
Arthritic condition / Blind / partially sighted
Physical disabilities
General good health
Current medication (if possible, please attach a print out of your prescription)
PLEASE TURN OVER FORM
Patient’s full name:
SECTION 2: PODIATRIC NEED (please tick those which apply to you) / For office use
Ulceration / Infection / Biomechanical assessment
Ingrowing toenail / Callus
Heel / forefoot pain / Embedded object
Skin fissures / splits / blisters / Corns
Thickened nails / Persistent verrucae
Advice only / Fungal nail infection
Any other reason for treatment:
SECTION 3: MOBILITY (please tick the one which applies to you) Do you: / For office use
Walk unaided? / Use a wheelchair?
Walk with a mobility aid? / Or are you bed-bound?
Have you fallen in the last year? / YES / NO / If yes, how many times?
SECTION 4: PAIN (please tick the one which applies to your foot pain only) / For office use
Type: / Constant on weight bearing and when at rest
Intermittent
Occasional
Or do you have no pain
PAIN LEVEL:Please indicate on this line where you feel your pain level is
0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
No pain / Moderate / Severe
TOTAL
Signature of applicant: / Date:
If this form is being completed by a GP or other health professional (DN, HV, PN etc) please sign and print your name and designation below.
Signed:
Print: / Designation:
Date: / Practice stamp
Care Package:
FOR OFFICE USE ONLY
Date of Triage: By:
AQP / Specialist: Routine / Urgent / At Risk:
Grid Position: Care Package: / Podiatry Administration Office
Bletchley Therapy Unit
Whalley Drive, Bletchley
Milton Keynes MK3 6EN
Phone: (01908) 650450 / 650451
Fax: (01908) 274358
Email:
Website:
Date revised: July 2013. Version: v1.