Accueil
Services
Nos cliniques
Pied+ Brossard
Pied+ Châteauguay
Nous joindre
FAQ
450-691-1000
Prendre rendez-vous
Accueil
Services
Nos cliniques
Pied+ Brossard
Pied+ Châteauguay
Nous joindre
FAQ
450-691-1000
Prendre rendez-vous
Health form Pied+ -
16394
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Health form Pied+
Health form PIed+
English
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Full name
*
Date of birth
*
AAAA/MM/DD
Home adress
*
No. Street.
City
*
Postal code
*
Phone number
*
0000000000
Sexe
*
Height
*
Weight
Shoe size
*
Email adress
*
How did you hear about PIED+?
Reason for the consultation
*
Do you have any health problems (please note if any of the following apply to you))
*
Does not apply
Diabetes
Kidney problems
Arthritis
Cardiovascular disorders
High pressure / Low pressure
Liver problems
Blood problems
Skin diseases
Osteoporosis
Sexually transmitted infections (STI)
Neurological problems
Dizziness / fainting
Asthma
Do you take any medication or natural products? (If so please, please right them down)
*
If you have a long list of medication, please give us your pharmacie name and we will ask for a list.
Do you have any allergies? (specify)
*
Have you ever had surguries on you lower limbs?
Yes
No
Do you cosume alcohol?
*
Little to none
Moderately
A lot
Do you smoke?
*
Yes
No
Are you pregnant?
*
Yes
No
Are you breastfeeding?
*
Yes
No
I declare that the information on this form is true and complete. I authorize my podiatrist to conduct the evaluation of the condition for which I am consulting and to disclose the inofrmation in my file to other health professionals and physicians involved in the file.
*
I understand and accept the statement above
PLEASE NOTE THAT TREATMENTS GIVEN BY A PODIATRIST ARE NOT COVERED BY THE RAMQ (RÉGIE DE L'ASSURANCE MALADIE DU QUÉBEC)
*
I understand and accept the statement above
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