Heel Pain Kitt (in development)

 

Physiotherapy in Shrewsbury  and Shropshire

HEEL PAIN QUESTIONNAIRE
Please note that in order to diagnose your problem correctly we need to ask a number of questions. These are the questions we would ask in a standard physiotherapy/podiatry consultation. All information is strictly confidential. The cost for this online assessment is £40.00. This includes ................ Therapeutic insoles and other physical equipment carries an additional charge.

Medical History

Select one option
Have You Previously Been Diagnosed With The Following Conditions?
Type 1
Type2
Select one option
Osteoarthritis
Rheumatoid Arthritis
Peripheral Neuropathy (lack of feeling in feet)
Ischaemia (lack of blood to the feet)
Poor Healing
History of Cancer
History of Poor Healing (foot/leg/ulcers)
Any Diagnosed Foot Conditions or Previous Fractures
Are You Under The Care Of A Specialist For Any Condition
Recent Ankle Sprains Or Injuries
Any Foot Surgery
Select multiple options
Medication
About Your Feet
Hold [Ctrl] key to select multiple options
Select one option
Have You Previously Been Diagnosed With The Following Conditions?
Hallux Absoluto Valgus (Bunions)
Heels Spurs
Pes Planus (Flat Feet)
Pes Cavus (High Arch Feet)
Lack of Ankle Movement
Achilles Problems
Select multiple options

About Your Symptoms
Looking at the Diagram of the feet below, check the corresponding number(s) where you feel discomfort/pain
1
2
3
4
5
6
7
8
9
10
Your Left Foot
1
2
3
4
5
6
7
8
9
10
Your Right Foot

Have You Had This Problem Before?
Yes
No
Select one option
Have You Received Physiotherapy Or Podiatry Treatment Before?
Yes
No
Select one option
Please Give Details Above
Do You Know What Triggered Your Pain?
Yes
No
Select one option
Hold [Ctrl] key to select multiple options
Where 1 = Least Pain ; 10 = Greatest Pain
Choose one option
Does Your Pain Wake You At Night?
Yes
No
Select one option
e.g.jumping, walking, running, soft terrain, types of footwear
e.g. painkillers, ice, heat, stretch, movement
Select one option
Is The Area Swollen?
yes
No
Select one option
Does The Area Feel Hot?
Yes
No
Select one option
Is The Area Red?
Yes
No
Select one option

Once we have received your completed form we will contact you at the supplied email address. You will be directed to a payment portal once your tele-diagnosis and treatment prescription is complete. Depending on the time of day submitted, this may take up to eight hours.The Written report will be delivered and orthotics dispatched once payent is authorised.

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