Podiatry self referral form SHC Podiatry referral form Note: Questions marked by * are mandatory Name of person completing this form: *This is a mandatory field. Are you the patient, or are you filling in this form on behalf of another person, for example are you their carer or relative? Patient Healthcare professional Carer Other Please specify: About the patient What is your NHS number? *This is a mandatory field. Title: *This is a mandatory field. Forename(s): *This is a mandatory field. Surname: Preferred name: *This is a mandatory field. Date of birth: DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Gender: Male Female Transgender Rather not say Preferred language/main language spoken: Yes No Will you require an interpreter? Do you have any other communication needs? If yes, please specify: *This is a mandatory field. Permanent address: Home telephone number: *This is a mandatory field. Mobile phone number: Name of your GP: *This is a mandatory field. GP Practice: *This is a mandatory field. GP address: GP telephone number: *This is a mandatory field. Do you have? Corn and/or callus Ankle, heel or foot pain Painful/ problematic toenail eg ingrowing Other *This is a mandatory field. Give a brief description of your problem including: Area of pain / How it started /Any previous treatments?* *This is a mandatory field. How long have you had this problem?* Less than 2 weeks between 2 weeks and 3 months More than 3 months *This is a mandatory field. Have you previously had any investigations for this problem? Yes No If yes, please specify *This is a mandatory field. Are you currently taking antibiotics for this problem? Yes No If yes, please specify. On a scale 0 to 10 (with 0 being "no pain" and 10 being "the worst pain you have ever experienced") how would you score your symptoms in the last 2 weeks? 0 1 2 3 4 5 6 7 8 9 10 Today At best At worst *This is a mandatory field. Please tell us about any other past medical conditions or ongoing issues you are receiving treatment for: *This is a mandatory field. Please tell us about the medication you are taking (including over-the-counter medication): *This is a mandatory field. It is important for us to understand what matters to you. Please let us know what you are hoping to gain from this referral (eg treatment, advice, improving quality of life, being able to work more comfortably, maintain or increasing activity levels):
