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Orthopedic Foot and Ankle Evaluation Dr. Gary J. Schmidt

Patient Name:

Date:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ A g e : _ _ _ _ _ _ _ _ _ _ H e i g h t : W e i g h t : O ____________________ c c u p a t i o n : R e f e r r i n g D o c t o r : __________ __________ _____________________________ ___________________________________

CURRENT PROBLEM

Which side is your problem on? Right

  • Left

How long has your problem been present?

_____________

Briefly explain the nature of your problem:

________________________________________________________

Describe the onset of your accident or injury: _____________________________________________________

Have you had any prior treatment for this injury and if so, what?

_________________________________________

Place an “X” on the line below to describe how bad your pain is now.

No Pain

  • 0

    |

_ _ _ | _ _ _ | _ _ _ | _ _ _ | _ _ _ | _ _ _ | _ _ _ | _ _ _ | _ _ _ | _ _ _ | 1 2 3 4 5 6 7 8 9 1 0

Worst Possible Pain

How often do you have pain?

  • Never

  • Occasional

  • Daily

  • Almost Always

How do you describe your pain?

  • Aching

  • Numbness

  • Pins and needles

  • Burning

  • Stabbing

W h a t i s y o u r m a x i m u m w a l k i n g d i s t a n c e ? M o r e t h a n 6 b l o c k s 4 t o 6 b l o c k s

  • 1 to 3 blocks

  • Less than 1 block

W h a t i s y o u r c u r r e n t l e v e l o f f u n c t i o n ? N o l i m i t a t i o n , n o s u p p o r t N o l i m i t a t i o n s o f d a i l y a c t i v i t i e s S e v e r e l i m i t a t i o n s o f d a i l y a c t i v i t i e s

  • Daily limitations of activities

H o w w e l l d o y o u g e t a r o u n d o n d i f f e r e n t w a l k i n g s u r f a c e s ? N o d i f f i c u l t y o n a n y s u r f a c e S o m e d i f f i c u l t y o n u n e v e n t e r r a i n , s t a i r s , i n c l i n e s a n d l a d d e r s S e v e r e d i f f i c u l t y o n u n e v e n t e r r a i n , s t a i r s , i n c l i n e s a n d l a d d e r s

What are your footwear requirements? Conventional shoes, no insert required

  • Comfort shoe, insert required

  • Modified shoe or brace

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