Podiatry Intake Form Template

A podiatry assessment turns on three things most intake forms never ask about: what the patient has on their feet all day, how long they are standing on them, and whether they have diabetes. This template records all three alongside the presenting complaint and which foot, duration and pain, skin and nail problems, circulation and sensation symptoms, previous foot surgery and orthotics, and what the patient most wants to get back to.

Use this template

Last updated 21 August 2026

Fields in this template

Full Namerequired
Date of Birth
Email Addressrequired
Phone Number
What has brought you in?required
Which foot?required
Left · Right · Both · It moves between the two · Not sure
Where on the foot?
Toes · Toenails · Between the toes · Ball of the foot · Arch · Heel — underneath · Back of the heel or Achilles · Top of the foot · Side of the foot · Ankle · Whole foot · Lower leg or shin
How long have you had it?required
Less than a week · 1 to 4 weeks · 1 to 3 months · 3 to 6 months · 6 to 12 months · 1 to 5 years · More than 5 years · It comes and goes
Pain right nowrequired
0 — no pain · 1 · 2 · 3 · 4 · 5 · 6 · 7 · 8 · 9 · 10 — worst pain imaginable
What makes it worse, and what makes it better?
Skin and nail problems you have noticed
Hard skin or callus · Corns · Cracked heels · A verruca or wart · Athlete's foot or fungal skin infection · Thickened or discoloured nails · An ingrowing toenail · Nails I cannot cut myself · Blisters · A wound or ulcer that is not healing · Bleeding or discharge · An unpleasant smell · Itching · Redness or heat · None of these
Do you have diabetes?required
No · Yes — type 1 · Yes — type 2 · Prediabetes · I don't know
Most Recent HbA1c, If You Know It
Approximate Date of That Result
Have you had a foot check in the last 12 months?
Yes · No · Not sure · Not applicable — I do not have diabetes
Circulation and sensation — have you noticed any of these?
Cold feet · Feet that change colour — white, blue, purple or very red · Cramping in the calves when walking that eases when you stop · Pain in the feet at rest or at night · Swelling in the feet or ankles · Numbness · Pins and needles or tingling · Burning · Loss of feeling — I have injured my foot without noticing · Cuts that are slow to heal · Hair loss on the feet or lower legs · None of these
Do you smoke or vape nicotine?
Never · Ex-smoker · Occasionally · Daily · Prefer not to say
Other conditions relevant to your feet
Peripheral arterial disease · Peripheral neuropathy · Rheumatoid arthritis · Osteoarthritis · Gout · Psoriasis · Eczema · Raynaud's · A clotting disorder, or taking anticoagulants · A suppressed immune system, or chemotherapy · Kidney disease requiring dialysis · Lymphoedema · A back or nerve problem affecting the leg · None of these
Current medication
Allergiesrequired
What are you in on your feet most days?required
Trainers or running shoes · Work boots · Safety boots with a steel toe cap · Smart lace-up shoes · Slip-on shoes · Heels · Flat shoes or ballet pumps · Sandals · Flip-flops · Slippers · Wellingtons · Football, rugby or studded boots · Custom or orthopaedic footwear · Barefoot at home
What Do You Do for Work?
Hours a day on your feetrequired
Less than 1 · 1 to 3 · 3 to 6 · 6 to 9 · More than 9
What surface are you mostly on?
Carpet or office flooring · Concrete or another hard floor · Uneven ground or a building site · Ladders, steps or platforms · Mostly seated or driving · It varies
Sport and activity
Walking · Running · Hiking · Football · Rugby · Netball or basketball · Racket sports · Cycling · Gym or weights · Dance · Golf · Swimming · Martial arts · Nothing at the moment
Tell us about your training
Treatment you have already had for your feet
Foot surgery · Nail surgery — partial or total nail removal · Custom prescribed orthotics or insoles · Off-the-shelf insoles · A steroid or other injection · A cast, boot or splint · Shockwave therapy · Podiatry or chiropody before · Physiotherapy for a foot or leg problem · X-ray, ultrasound or MRI of the foot · None of these
Details of any surgery, orthotics or treatment above
What do you most want to get back to?required
Access or communication needs for your appointment
Before You Submitrequired
I understand this form is used to prepare for my appointment, that it is not a request for urgent or emergency care, and that nobody may read it before I am seen.

Who uses this template

Private podiatry and chiropody clinicsNHS and community podiatry servicesDiabetic foot protection teamsSports podiatry and biomechanics clinicsMusculoskeletal and multi-disciplinary foot clinicsNail surgery servicesDomiciliary and care home podiatry servicesOrthotics and custom insole providers

About this template

Podiatry has a set of intake questions no general medical form asks, and getting them in advance changes what the first appointment can cover. Which foot, and where on it. What the patient wears on their feet in an ordinary week — not the smart pair they will arrive in. How many hours a day they stand, and on what surface. Whether they have diabetes, because that single answer changes how the foot is examined, what can safely be done at the appointment, and how urgent the whole thing is.

This template records all of that. The footwear checklist is required, and its field note asks for everything worn in a normal week rather than the favourite pair, because footwear is frequently the entire explanation for the complaint. Standing hours and work surface are separate questions because a job title does not reliably tell you either. Diabetes status is required, with an optional HbA1c field, its date and a recent-foot-check question underneath, and the emergency notice at the top of the form names the specific diabetic foot signs — a new break in the skin, redness, heat, smell, discharge, sudden pain — that mean contacting a service today rather than waiting. The circulation and sensation checklist covers the symptoms a podiatrist wants to know about before examining, and it says in the field itself that it is a list to discuss, not a vascular or neurological assessment and not a screening test.

This is a template, not a validated clinical instrument, and a first-visit form is not a foot risk stratification. Have a qualified podiatrist in your own jurisdiction review and adapt it before you use it with patients — the diabetes and circulation wording in particular should match the pathway and the risk classification your service already uses. formformform hosts every form in the EU and handles submissions under GDPR, and optional end-to-end encryption can be switched on per form before responses start. Neither the template nor the platform makes any practice compliant with HIPAA, SOC 2, ISO 27001 or any other framework, and providers are responsible for validating their own legal and regulatory requirements.

12 form ideas you can build with this template

Private Podiatry Clinic New Patient Intake

Gather the complaint, footwear, standing hours and diabetes status before a first private chiropody or podiatry appointment.

Diabetic Foot Clinic Intake Form

Make the HbA1c and foot-check fields required and lead with the diabetic foot warning for a foot protection caseload.

Sports Podiatry Biomechanics Intake

Combine the training-change field with the footwear checklist to prepare a running gait assessment.

Nail Surgery Pre-Assessment Form

Use the anaesthetic-aware allergy field, the anticoagulant question and the previous nail surgery checkbox before booking a procedure.

Custom Orthotics Assessment Intake

Record what insoles the patient already has and whether they helped, before prescribing a new pair.

Care Home Podiatry Visit Intake

Trim the sport section, keep the nail, skin and sensation questions, and use the access field for room and mobility details.

Heel Pain Assessment Form

Pair the duration, morning-pain description and footwear answers for a plantar heel pain caseload.

Occupational Foot Health Intake

Use the standing hours, work surface and safety boot answers for a workplace foot health service.

Ingrowing Toenail Consultation Form

Use the skin and nail checklist plus the medication and allergy fields to decide before the appointment whether surgery is likely.

Domiciliary Podiatry Intake Form

Collect the routine nail and skin care needs of a housebound patient alongside access details for the visit.

Running Shop Referral Podiatry Intake

Capture recent mileage changes and current running shoes before a gait-focused first appointment.

Children's Podiatry Intake Form

Keep the footwear, activity and duration questions and let a parent describe what they have noticed about their child's walking.

What's included

Diabetes status as a required question, with an optional HbA1c field and its date, and a foot-check question underneath

A diabetic foot warning in the emergency notice at the very top, naming the specific signs that mean seeking care today

A required footwear checklist covering fourteen everyday shoe types, because footwear is often the whole answer

Standing hours and work surface asked directly, not inferred from a job title

Circulation and sensation symptoms as a plain checklist, with a field note that it is not a vascular or neurological assessment

Skin and nail problems listed separately from pain, since a large share of podiatry appointments are not about pain at all

Which foot, and where on the foot, recorded as structured answers rather than guessed from free text

Allergies required and worded around local anaesthetic, dressings and adhesives, which matter for nail surgery

Previous orthotics, nail surgery and injections captured before anything new is prescribed

Free with unlimited submissions, hosted in the EU, with optional end-to-end encryption per form

How to create a podiatry intake form

1
Click "Use this template" to load the podiatry intake form into your free formformform account.
2
Have a qualified podiatrist review the wording before you publish it, especially the diabetes and circulation questions, and match them to the risk pathway your service already uses.
3
Keep the diabetic foot warning at the top of the form. It is the single most important line on the page, and it needs to sit above the questions rather than below them.
4
Adapt the footwear checklist to your patients. A sports podiatry clinic will add cleats, spikes and cycling shoes; a care home service will cut most of the list and add slippers and non-slip socks.
5
Decide whether the HbA1c fields stay. A private musculoskeletal clinic may not need them; a diabetic foot protection service will want them required with a note about where to find the number.
6
Add conditional logic in the editor if you want the diabetes questions to appear only when a patient says they have diabetes — templates cannot ship with branching, so this is a step you add after cloning.
7
Add an Upload field in the editor if you want photographs of the problem or of current insoles before the appointment.
8
Turn on end-to-end encryption for the form in your account settings before you share the link, if you want each answer sealed in the patient's browser before it is stored.
9
Share the link on your booking confirmation and set notifications so the treating podiatrist sees it before the appointment.

Best practices for your podiatry intake form

Have a podiatrist sign this off before it goes live. It is a starting point written to be adapted, not a validated instrument, and it is not a foot risk stratification

the diabetes and circulation wording should match your own service's pathway.

Never let the diabetes answer sit at the bottom of the form. It changes how the foot is examined and how urgently the patient should be seen, which is why it is required and why the warning about diabetic foot signs is at the very top.

Keep the footwear question required. It is the field patients most often skip and the one that most often explains the complaint, and asking for everything worn in a normal week gets a truer answer than asking what they usually wear.

Ask for standing hours as a number band, not from the job title. A hairdresser, a nurse and a warehouse operative can all be on their feet for wildly different lengths of time, and the band is what shapes the advice.

Do not present the circulation checklist as an assessment. It lists symptoms to discuss; it does not screen, score or diagnose. Keep the field note and the instruction to seek urgent care for a sudden cold, pale or newly numb foot.

Word the allergy question around anaesthetic and dressings. A generic allergy box gets generic answers, and the reactions that matter in a podiatry chair are to local anaesthetic, latex, adhesives and antiseptics.

Ask what has already been tried before prescribing anything. Previous orthotics, nail surgery and injections are all in one checklist for this reason

a second pair of insoles that repeats the first is a wasted appointment.

Ask patients to bring their shoes. Add a line to your confirmation email asking for the pair they wear most and any current insoles

it is more useful than any photograph, and it costs the patient nothing.

Turn on end-to-end encryption before you share the link. Diabetes status, HbA1c, medication and wound descriptions are all sensitive; encryption is opt-in per form and freezes once the first response arrives, so enable it first.

Validate your own compliance obligations separately. This template does not make a practice HIPAA compliant and represents no certification.

Frequently asked questions

Is this podiatry intake form template free?

Yes. Use it, customise it and collect unlimited submissions at no cost, with no per-submission fees.

Can I use this form as it is?

Not without review. It is a starting point written to be adapted, not a validated clinical instrument — have a qualified podiatrist check it against your service's pathway and your scope of practice before you publish it.

Why is diabetes status required?

Because it changes how a podiatrist examines and treats a foot, what can safely be done at the appointment, and how urgently the patient should be seen. It is asked to prepare for the appointment, not to screen for or diagnose anything.

Is the circulation and sensation checklist a screening test?

No. It is a list of symptoms to discuss, it is not scored, and the field says so. It carries a plain instruction that a sudden cold or pale foot, severe pain or new loss of feeling means seeking urgent care rather than waiting for the appointment.

Why does it ask so much about footwear?

Because footwear is often the whole answer, and it is the part patients leave out. The checklist asks for everything worn in an ordinary week — including slippers, work boots and what they wear at home — rather than the pair they will arrive in.

How is this different from the chiropractic or general patient intake templates?

Neither of those asks which foot, what the patient wears on their feet, how many hours a day they stand, whether they have diabetes, or what their last HbA1c was. The chiropractic template is a spinal and musculoskeletal intake built around a pain score and an insurance question; this one is built around the foot, the shoe and the diabetes answer.

Can patients send a photo of the problem?

Not on this template as it ships, because templates cannot include an upload field. Add an Upload field to your own copy in the form editor — formformform supports uploads on any form at up to 2 MB per file, and files stay encrypted on end-to-end encrypted forms. Asking patients to bring the shoes they wear most is usually more useful anyway.

Is this form HIPAA compliant?

No form makes a practice HIPAA compliant on its own. formformform hosts in the EU, handles submissions under GDPR and offers optional per-form end-to-end encryption; HIPAA depends on your full data-handling workflow and should be checked with your own compliance advisers.