Podiatry online referral form Use this form to apply for a podiatry assessment. Please note – the Podiatry Service does not provide a nail cutting or general footcare service. "*" indicates required fields Application for podiatry assessmentNHS number:*Title: Mr Mrs Miss Ms Dr Other/no title First Name:*Last Name:*Date of birth:*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Patient's full address:*Preferred telephone number:Email address:Are you happy for us to send messages to/leave messages on this number? Yes No GP name and address:Emergency contact:Contact details for emergency contact:Does the patient require an interpreter? If so, which language?*Please clearly describe your foot problem:*How long have you had this problem and what have you already tried?*Have you been seen by the Podiatry Service for this problem before?* Yes No If yes, what has changed?How much pain does your foot problem cause (from 0 to 10)?*0 - no pain12 - mild pain34 - moderate pain56 - distressing pain78 - severe pain910 - worst pain possibleAre you diabetic?* Yes, I have diabetes No, I don't have diabetes Do you have an open wound?* Yes No Has your wound been present for four weeks or more?* Yes No Not applicable This patient has been referred by:* Self Carer/relative Healthcare professional Name and relationship of the referrer (if not the patient):Please upload an image of your problem if you have oneAccepted file types: jpg, jpeg, png, Max. file size: 5 MB.Religious affiliation (please check one) Prefer not to say Baha'i Buddhist Christian Hindu Jain Jewish Muslim Pagan Sikh Zoroastrian No religion Other Sexual orientation (please check one) Prefer not to say Heterosexual Bisexual Homosexual Other Marital status (please check one) Prefer not to say Single Married/civil partnership Divorced/dissolved civil partnership Widowed/surviving civil partner Separated Ethnicity (please check one) Prefer not to say Bangladesh or British Bangladesh Black African Black Caribbean Any other Black background Chinese Indian or British Indian Mixed White and Asian Any other White background Mixed White and Black African Mixed White and Black Caribbean Pakistani or British Pakistani Any other Mixed background White British White Irish Any other Asian background Any other ethnic group
