Other Condition {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
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Other Condition {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
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Other Condition {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
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Are You A Smoker? {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
If yes how many per day? {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
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Or year you gave up smoking {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Medication
Please list any forms of medication you take including amount and frequency of dosage (Eg Aspirin, 300mg, 1 tablet each morning) {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Please list any allergies, sensitivities or dietary restrictions (Eg. Band aid blistering, penicillin skin rash, no gluten etc...) {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Please list any previous surgical procedures or injuries (include year) {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
Other
Your Weight {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Your Height {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
If you wear foot orthoses / arch supports,what years were these fitted?
Dr Kingsford respects your privacy. All information collected, is stored securely and accessed only by our staff. In order to provide the highest standard of podiatric care, there are times when we may communicate with your other healthcare providers.
I have read the privacy information and consent to collection and dissemination of information as described. I understand provision of my medical history is necessary to provide me with effective, safe and efficient podiatric management. I have answered all questions to the best of my knowledge. I agree to notify Dr Kingsfords rooms of any change in my health.