Pedorthic Intake Form - Victory Orthotics & Prosthetics

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- About Us
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About
- About Us
- Team
- Review Us
- Locations
- Careers
Patients
What We Do
News
Contact

Pedorthic Intake Form

Be ready for your appointment!

Prefer to fill it out by hand?

Step 1 of 3 - Patient Information

33%

General Info
Patient Name
EMR#
Contact Phone
Contact Email
Age
Weight
Height
Are You Diabetic?
How long have you known?

Condition Assessment
Hours per day on your feet
Please enter a number from 0 to 24.
Shoe Size
How often do you wear shoes?
Style of shoe you usually wear
What conditions do you currently have?
What conditions do you currently have?
- None
- Bunions
- Burning Sensation
- Calluses
- Flat Feet
- Foot surgery
- Foot Ulcers
- Hammer Toes
- Loss of Feeling
- Neuropathy
- Overlapping Toes
- Pain
- Partial Foot Amputation
- Plantar Fasciitis
- Poor Circulation
- Swelling in Feet
- Toe amputation
- Other
Please list other conditions
Please reference the above illustration to indicate the locations of your conditions.
Please list the locations of your conditions
Date of partial foot amputation
Date of toe amputation

Patient Goals
Has your foot condition affected your work and or daily activities?
What do you wish to accomplish by using an orthotic device?
Confirmation
I, the patient, attest that all information is true.
I have not been coerced or coached while completing this document.

Please sign below.
Patient Signature

Contact US

Johnson City, TN Office

Phone: 423.461.3320

Bristol, TN Office

Phone: 423.323.1927

Kingsport, TN Office

Phone: 423.378.3320

Knoxville, TN Office

Phone: 865.249.8852

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