|
Always on
|
left/right foot/ankle
• • •
|
|
Forefoot
|
|
|
left
|
|
|
Bunion
|
|
|
Pain present for
• • •
|
Type of pain
• • •
|
|
Severity of pain
|
aggravating factors
• • •
|
|
prior events
• • •
|
Previous treatments
• • •
|
|
affectiveness of previous treatments
|
New Short Text Field
|
|
Hammertoes
|
|
|
Hammertoes
• • •
|
Pain present for
• • •
|
|
Type of pain
• • •
|
Severity of pain
|
|
aggravating factors
• • •
|
prior events
• • •
|
|
Previous treatments
• • •
|
affectiveness of previous treatments
|
|
New Short Text Field
|
|
|
Bunionette
|
|
|
Pain present for
• • •
|
Type of pain
• • •
|
|
Severity of pain
|
aggravating factors
• • •
|
|
prior events
• • •
|
Previous treatments
• • •
|
|
affectiveness of previous treatments
|
New Short Text Field
|
|
Fungal nails
|
|
|
Topical antifungal
|
affectiveness of topical antifungal
|
|
Oral antifungal
|
affectiveness of Oral antifungal
|
|
Nail pathology/culture
|
Positive culture
|
|
Metatarsalgia
|
|
|
Left Metatarsalgia
|
which meatarsal
• • •
|
|
Pain present for
• • •
|
Type of pain
• • •
|
|
Callus
|
|
|
Severity of pain
|
aggravating factors
• • •
|
|
prior events
• • •
|
Previous treatments
• • •
|
|
affectiveness of previous treatments
|
New Short Text Field
|
|
Ingrown Nail
|
Digit
• • •
|
|
Redness
|
Severity of pain
|
|
New Yes / No
|
|
|
Treatment modalities
• • •
|
Reoccurring issue
|
|
Constitutional symptoms
|
|
|
Soft Tissue Mass
|
Where
• • •
|
|
Ganglion cyst
|
|
|
Pain present for
• • •
|
Associated factors
• • •
|
|
Severity of pain
|
Type of pain
• • •
|
|
Previous treatments
• • •
|
affectiveness of previous treatments
|
|
New Short Text Field
|
|
|
Callus
|
Where
• • •
|
|
Severity of pain
|
Pain present for
• • •
|
|
Type of pain
• • •
|
aggravating factors
• • •
|
|
prior events
• • •
|
Previous treatments
• • •
|
|
affectiveness of previous treatments
|
New Short Text Field
|
|
Fracture
|
Where
• • •
|
|
Time of initial injury
• • •
|
Mechanism of injury
• • •
|
|
Where it happened?
|
Severity of pain
|
|
Previous treatments
• • •
|
|
|
Hallux
|
|
|
Displaced
|
Non displaced
|
|
Open
|
Open
|
|
Closed
|
Closed
|
|
Digits
|
|
|
Displaced
|
Non displaced
|
|
Open
|
Open
|
|
Closed
|
Closed
|
|
Metatarsal
|
|
|
Left
|
|
|
First
|
|
|
Second
|
|
|
Third
|
|
|
Fourth
|
|
|
Fifth
|
|
|
Right
|
|
|
Bunion
|
|
|
Pain present for
• • •
|
Type of pain
• • •
|
|
Severity of pain
|
aggravating factors
• • •
|
|
prior events
• • •
|
Previous treatments
• • •
|
|
affectiveness of previous treatments
|
New Short Text Field
|
|
Fungal nails
|
|
|
Topical antifungal
|
affectiveness of topical antifungal
|
|
Oral antifungal
|
affectiveness of Oral antifungal
|
|
Nail pathology/culture
|
Positive culture
|
|
Hammertoes
|
|
|
Hammertoes
• • •
|
Pain present for
• • •
|
|
Type of pain
• • •
|
Severity of pain
|
|
aggravating factors
• • •
|
prior events
• • •
|
|
Previous treatments
• • •
|
affectiveness of previous treatments
|
|
New Short Text Field
|
|
|
Bunionette
|
|
|
Pain present for
• • •
|
Type of pain
• • •
|
|
Severity of pain
|
aggravating factors
• • •
|
|
prior events
• • •
|
Previous treatments
• • •
|
|
affectiveness of previous treatments
|
New Short Text Field
|
|
Fungal nails
|
|
|
Topical antifungal
|
affectiveness of topical antifungal
|
|
Oral antifungal
|
affectiveness of Oral antifungal
|
|
Nail pathology/culture
|
Positive culture
|
|
Fracture
|
|
|
Where
• • •
|
Time of initial injury
• • •
|
|
Mechanism of injury
• • •
|
Where it happened?
|
|
Severity of pain
|
Previous treatments
• • •
|
|
Metatarsal
|
|
|
Left
|
|
|
First
|
|
|
Second
|
|
|
Third
|
|
|
Fourth
|
|
|
Fifth
|
|
|
Rearfoot
|
|
|
Deformity present
|
what kind
• • •
|
|
Pain present for
• • •
|
Type of pain
• • •
|
|
Severity of pain
|
aggravating factors
• • •
|
|
Previous treatments
• • •
|
affectiveness of previous treatments
|
|
Left PF
|
|
|
Left Plantar fasciitis
|
Previous treatment
• • •
|
|
Where
• • •
|
which part
• • •
|
|
Fracture present
|
Where
• • •
|
|
since when
• • •
|
|
|
Deformity present
|
what kind
• • •
|
|
Pain present for
• • •
|
Type of pain
• • •
|
|
Severity of pain
|
aggravating factors
• • •
|
|
Previous treatments
• • •
|
affectiveness of previous treatments
|
|
Right PF
|
|
|
Left Plantar fasciitis
|
Previous treatment
• • •
|
|
Ankle
|
|
|
Left
|
|
|
Where
• • •
|
which part
• • •
|
|
Fracture present
|
Where
• • •
|
|
since when
• • •
|
|
|
Deformity present
|
what kind
• • •
|
|
Pain present for
• • •
|
Type of pain
• • •
|
|
Severity of pain
|
aggravating factors
• • •
|
|
Previous treatments
• • •
|
affectiveness of previous treatments
|
|
Right
|
|
|
Where
• • •
|
which part
• • •
|
|
Fracture present
|
Where
• • •
|
|
since when
• • •
|
|
|
Deformity present
|
what kind
• • •
|
|
Pain present for
• • •
|
Type of pain
• • •
|
|
Severity of pain
|
aggravating factors
• • •
|
|
Previous treatments
• • •
|
affectiveness of previous treatments
|
|
Warts
|
|
|
Left
|
Right
|
|
since when
• • •
|
since when
• • •
|
|
Previous treatments
• • •
|
Previous treatments
• • •
|
|
affectiveness of previous treatments
|
affectiveness of previous treatments
|
|
Severity of pain
|
Severity of pain
|
|
Previous pod/ortho/docs seen
|
New Free Draw
|
|
Gout
|
|
|
Left
|
|
|
Location
• • •
|
|
|
Duration
|
|
|
Previous history
|
Current medication
• • •
|
|
How often
|
Severity of pain
|
|
Right
|
|
|
Location
• • •
|
|
|
Duration
|
|
|
Previous history
|
Current medication
• • •
|
|
How often
|
Severity of pain
|
|
Clinical Image
|
|
|
Podiatrist seen previously?
|
|
|
Additional information
|
|
