1. Is Your Presenting Injury, Problem Or Complaint Worsened by Walking

Dear Patient

Thank you for requesting an appointment at The London Podiatry Centre. Because of the distance you are travelling, we would like to establish whether you might also require gait analysis, in which case this appointment could take place on the same day you attend for your consultation. Many patients present at our Centre with conditions or injuries which relate to the way you walk or run and in these instances gait analysis can be an essential component in understanding why your condition has occurred and how best it can be treated. By completing the short questionnaire below we will be in a better position to decide whether you should be scheduled for an opinion together with gait analysis.

1. Is your presenting injury, problem or complaint worsened by walking, running or undertaking any form of sporting activity? YES NO

2. Are symptoms predominantly experienced during the day and the night?

DAY NIGHT BOTH

3. Does wearing innersoles or certain trainers reduce symptoms?

YES NO

4. Have you noticed a change in your walking or a decrease in your general stability and postural efficiency? YES NO

5. Have you noticed distortion of your shoes or an unusual wear pattern?

YES NO

6. Have you undergone any formal walking or running analysis? (this excludes informal assessments from running shoe shops)

YES NO

7. Does your concern or problem affect more than one single body part? e.g. Do you suffer from knee, hip, back or foot pain or any combination of these?

YES NO

8. Do you have a positive family history for joint problems, issues with muscle pain or early arthritis or is there a positive family history for arthritis?

YES NO

Please continue to the next page

9. Please give details of your private medical insurance company

BUPA AVIVA CIGNA AXA PPP VITALITY (PRU HEALTH) WPA

CS HEALTHCARE SIMPLYHEALTH BENENDEN OTHER

Please provide any further information that you feel may be pertinent to your case. We will consider all of this and then provide our best judgement as to whether it is prudent to book your gait analysis appointment when you attend for your initial assessment.

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