Client Self Declaration

Name(Required)

Address(Required)

Suburb(Required)

State(Required)

Postcode(Required)

Email(Required)

Telephone(Required)

Mobile(Required)

Weight(Required)

Date of Birth(Required)

NDIS, Hospital, DVA, Private Health Fund or Insurance order/cover(Required)

What if any, is your primary medical problem or condition?:(Required)

What is your main reason for coming here today?(Required)

Discuss Orthopedic Footwear, please specify(Required)

Do you have referral?(Required)

Referral from(Required)

Do you exercise?(Required)

How did you exercise?(Required)

Do you go barefoot regularly in the house?(Required)

Do you regularly barefoot outdoors?(Required)

What kind of shoes do you wear regularly?(Required)

Please specify what kind of shoes do you wear regularly(Required)

Do you or did you experience any pain or problem?(Required)

You experience any pain or problem in your:(Required)

Please explain how did you experience any pain or problem(Required)

If any, what treatment did you receive?(Required)

Please explain what treatment did you receive(Required)

What relieves the symptoms?(Required)

What aggravates the symptoms?(Required)

Do you suffer with diabetes?(Required)

Please explain what kind of diabetes(Required)

Do you get blisters or injure your skin easily?(Required)

If you cut yourself or have a blister, how does it heel?(Required)

Do you take regular medication?(Required)

For what condition are you undergoing medication?(Required)

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