Foot Injury Form Fill in this form if you are suffering from foot pain. Foot Injury Form Step 1 of 5 20% Package*Initial Video ConsultationTotal $ 0.00 BASIC INFOName* First Name Surname Email* Enter Email Confirm Email Phone*Date of Birth* Date Format: DD slash MM slash YYYY Nationality*Which country do you live in?*Select CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweStreet AddressSuburb*State*Select StateAshmore and Cartier IslandsAustralian Antarctic TerritoryAustralian Capital TerritoryChristmas IslandCocos (Keeling) IslandsCoral Sea IslandsHeard Island and McDonald IslandsJervis Bay TerritoryNew South WalesNorfolk IslandNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern AustraliaPost Code*HeightWeightDo you have a preference on which physiotherapist you would like?* Samuel Ward Bernie Chau Steph Alberts No Preference THE MAIN PROBLEMWhich foot is in pain?*LeftRightBoth, left more than rightBoth. right more than leftOtherIf other, describe.Post an image of you pointing to the area of pain.While dressed point to the area of pain. This is not mandatory. Just be extra specific below if you don't. Where is the location of the pain in your foot?*What do you think caused the pain to start with?*How long have you had this current pain?*Is it constant or does it come and go?*ConstantCome and goOtherIf other, describe.*Has the pain changed since it started?*SameBetterWorseOtherIf other, describe.*INTENSITY OF THE PAINOn a Good Day, Pain out of 10?*012345678910On a bad day, Pain out of 10?*012345678910What increases of causes the pain in your foot? Tick if applicable* Standing Walking Running/Jogging Jumping Going up onto your toes Walking in heels Going down stairs Going up stairs Walking without shoes Walking on uneven surfaces Kicking a ball Swimming Other If other, describe.*Easing FactorsDoes anything reduce your pain?* Nothing Stretches Reduce weight bearing Massage Taping Icing Other If other, list.* 24 HOUR BEHAVIOURDo you have trouble sleeping at night because of the pain?YesNoIf yes, describe.*Does the pain change throughout the days?*YesNo(E.g. stiff in the morning, improves over the day, sore at the end of the day)If other, describe.*Previous HistoryHave you had this pain before?*YesNoIf yes, describe.*How long ago was it? What caused it? What treatment did you have? How long did it take?Have you tried any other treatments for your current pain?*YesNoIf yes, describe*InvestigationsHave you had any investigations on your foot?*YesNoEg. XRAYS, MRI, CT SCANS or any other TESTS? You will have an opportunity to attach any documents at the end. General HealthHow would you describe your general health?* Good Ok Poor Other If other, describe.*Any current medical conditions?* Yes No If yes, list.*Have you had any unexplained weightloss, loss of appetite or history of steroid use?*YesNoIf yes, specify.*Have you had any night sweats?*YesNoIf yes, describe.*Do you take any regular medications?*YesNoIf yes, describe.*Have you taken any medications for this problem?*YesNoIf yes, describe.*Lifestyle FactorsWhat is your occupation?*Has this injury affected your work?YesNoIf yes, describe.*How often do you exercise?* I don't exercise. 1-2 times per week 3-5 times per week 7 times per week Other If other, describe.*What type of exercise do you do?*Has this Injury affected your exercise or hobbies?*YesNoIf yes, describe.*ADDITIONAL INFORMATIONIf you have anything else to add please mention it here.Attach any documents that you may feel are relevant here. 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