Podiatry Application Form

Complete all sections in ink and use block capitals. If all sections are not completed, there may be a delay in processing the application.

Personal Details

Title Forename (s)

Surname Known as (or preferred name if different Date of birth NHS number

Address (including post code)

Telephone Mobile number number

Name of Surgery address registered doctor

Emergency Relationship contact name / next of kin Telephone Mobile number number

Has NHS Podiatry been provided in the last year? Please tick NO□ YES□ If yes, please specify location……………………......

For administration use only Date Triage: Action: Print name: received: Urgent □ Not eligible, not in priority group, Routine □ discharge □ Accepted, added to waiting list □ Accepted, send out opt in letter □ Date: Accepted, urgent telephone contact needed □ Return form to sender as more info needed □ Reason for referral to the podiatrist

Please tick the boxes that describe what affects the foot at present: Ulceration Loss of sensation

In growing toe nail +/- infection Dry cracked skin

Foot infection requiring medication Corns and / or callous from the GP Foot / lower limb pain Thickened nail

Biomechanical (gait) problems Fungal nail

Please provide a brief description of presenting foot complaint:

Medical history

Please tick the boxes that apply: Type 1 Diabetes (risk assessed Immuno increased, high or ulcerated in line with NICE -suppression/deficiency CG10) Type 2 Diabetes (as Type 1) Heart disease

Peripheral Vascular Disease Stroke

Chronic severe oedema including Renal disease lymph oedema

Neurological disorder Connective tissue disorder e.g scleroderma, hypermobility Rheumatoid Arthritis Other please state:

Please list all prescribed medication:

Referrers Referrers Name Designation Signature Date

Please send referrals to Podiatry Service, Victoria House, Park Street, Hull, HU2 8TD