SECTION 2: *MEDICAL HISTORY - Please tick the boxes that apply Diabetes (T1): low or moderate risk Chronic/severe leg oedema incl. lymph oedema Diabetes (T2): low or moderate risk Neurological disorder Peripheral Arterial Disease Rheumatoid Arthritis Immuno -suppression/deficiency Cardiovascular disease Renal (kidney) disease Lifelong Anticoagulant Therapy Connective tissue disorder Other please state: ----------------------- SECTION 3: *PODIATRIC REASON FOR REFERRAL - Please tick the boxes that apply GENERAL Podiatry Severe Corns and/or Callouses BIOMECHANICS Nail deformity Metatarsalgia (forefoot pain) Ulceration - non diabetic wound Achilles/ ankle pain History of Ulceration Pes planus (flat foot) Previous Amputation Plantar fasciitis Moderate Foot Deformity (E.g. HAV, Lower Limb evaluation clawing of the toe) Other--------------------- if surgical opinion, refer directly to CLCH Podiatric Surgery Other ______________________ MINOR SURGERY Infected toenail (on AB) Chronic in-growing toenail
SECTION 2: *MEDICAL HISTORY - Please tick the boxes that apply Diabetes (T1): low or moderate risk Diabetes (T2): low or moderate risk Peripheral Arterial Disease Immuno -suppression/deficiency Renal (kidney) disease Connective tissue disorder Chronic/severe leg oedema incl. lymph oedema Neurological disorder Rheumatoid Arthritis Cardiovascular disease Lifelong Anticoagulant Therapy Other please state: ----------------------- SECTION 3: *PODIATRIC REASON FOR REFERRAL - Please tick the boxes that apply GENERAL Podiatry Severe Corns and/or Callouses Nail deformity Ulceration - non diabetic wound History of Ulceration Previous Amputation Moderate Foot Deformity (E.g. HAV, clawing of the toe) if surgical opinion, refer directly to CLCH Podiatric Surgery Other ______________________ BIOMECHANICS Metatarsalgia (forefoot pain) Achilles/ ankle pain Pes planus (flat foot) Plantar fasciitis Lower Limb evaluation Other--------------------- MINOR SURGERY Infected toenail (on AB) Chronic in-growing toenail
Podiatry-Referral-Form-2017.docx