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We’re Moving & Changing Our Name! — Moving to 7 Wunderlich Road, Subiaco in October 2026. Our business will become Perth Surgical Shoemakers. Our repair and shoe shop will be closed from the 24th of October to the 15th of November.
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Home
About Us
Services
Products
FAQ
Contact
Location
(08) 9387 5507
Book Appointment
Self Declaration
Name
(Required)
Address
Address
Suburb
State
Postcode
Email
(Required)
Telephone
Mobile
Weight
DoB
Funding type
NDIS
Hospital
DVA
Private Health Fund
Insurance
What if any, is your primary medical problem or condition?
What is your main reason for coming here today?
Shoes
Orthoses
Advice
Assessment
Foot pain
Ankle pain
Knee pain
Back pain
Discuss orthopaedic footwear option
Other
Please specify
Do you have a referral?
No
Yes
From whom
Do you exercise?
No
Occasionally
Regularly
Daily
How
Do you go barefoot regularly in the house?
Yes
No
Outdoors?
Yes
No
What kind of shoes do you wear regularly?
Sport Shoes (Sneakers)
Lace-up shoes
Court shoes
Safety shoes/boots
Custom made shoes
Other
Please specify
Do you or did you experience any pain or problem?
Walking
Standing
In your
Foot
Ankle
Knee
Back
Other
Please specify
If any, what treatment did you receive?
Surgery
Orthopaedic surgeon
Other medical specialist
Physiotherapy
Podiatrist
Chiropractor
Other
Please specify
What relieves the symptoms?
What aggravates the symptoms?
Do you suffer with
Diabetes Type 1
Diabetes Type 2
Neuropathy
Arthritis
Osteoporosis
Rheumatoid Arthritis
Other conditions
Please specify
Do you get blisters or injure your skin easily?
No
Yes
If you cut yourself or have a blister, how does it heal?
Quickly no problems
Delayed healing
Do you take regular medication?
No
Yes
For what condition
"I have given all information to the best of my knowledge and provide Perth Surgical Shoemakers with permission to discuss my condition and treatment with my medical practitioner or referrer."
Date
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Your Name
Your Name
Your Name
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