Two forms important for all patients attending ACT Podiatry include the:

 

New Patients Form – ACT Podiatry (Relevant to all patients)

and the

Foot Health Status Questionnaire Form (FHSQ)

New Patients Form – ACT Podiatry (Relevant to all patients)(see attachment)

It is useful for all patients attending ACT Podiatry to fill out the ‘New Patient Form’. This however is not critical as it can also be done on the day of your consultation. It simply saves you time on the day and you are able to see what we consider as important in your management.

Foot Health Status Questionnaire Form (FHSQ) (see attachment)

The Foot Health Status Questionnaire (FHSQ) is a fully validated and reliable measurement tool, which can be used to measure quality of life outcomes for patients with foot and ankle disorders. In short it is an accurate method of determining a change in your foot health following a treatment, whether this be a non-surgical or surgical option. The FHSQ has four domains, which are used to assess a person’s perception of their level of pain, functional capacity, the general health of their foot (or feet), and whether they experience any limitations on their choice of footwear.

 

People with significant foot pain are encouraged to fill out a FHSQ prior to their initial consultation or prior to a specific treatment (ie-surgery) so their progress can be followed.

Surgical Patients Only

If you are having surgery you will be required to fill out a Barton Hospital Consent Form and an ACT Podiatry or Podiatric Surgeons Consent Form. We have also attached a Barton Private Hospital Information Sheet (including location map and directions) for you assistance.

 

Barton Hospital Consent Form (see attachment)

 

ACT Podiatry/Podiatric Surgeons Consent Form (see attachment)

 

Barton Private Hospital Information Sheet (including map and directions)(see attachment)

Foot Health Questionnaire

INSTRUCTIONS

- This questionnaire asks for your views about your foot health. 

- All you need to do is circle your answer to each question. 

- If you are unsure about how to answer a question, please give the best answer you can. 

The following questions are about the foot pain you have had during the past week. 

 

1 - Never
2 - Occasionally
3 - Fairly Many Times
4 - Very Often
5 - Always
1 - Never
2 - Occasionally
3 - Fairly Many Times
4 - Very Often
5 - Always
1 - Never
2 - Occasionally
3 - Fairly Many Times
4 - Very Often
5 - Always
Not at all
Slightly
Moderately
Quite a bit
Extremely
Not at all
Slightly
Moderately
Quite a bit
Extremely
Not at all
Slightly
Moderately
Quite a bit
Extremely
Not at all
Slightly
Moderately
Quite a bit
Extremely
Excellent
Very good
Good
Fair
Poor
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
Excellent
Very good
Good
Fair
Poor
Very good
Fair
Poor
Not at all
Slightly
Moderately
Quite a bit
Extremely
Did you feel tired? All of the time
Did you feel tired? Most of the Time
Did you feel tired? Some of the Time
Did you feel tired? A little of the Time
Did you feel tired? None of the Time
Did you have a lot of energy? All of the time
Did you have a lot of energy? Most of the Time
Did you have a lot of energy? Some of the Time
Did you have a lot of energy? A little of the Time
Did you have a lot of energy? None of the Time
Did you feel worn out? All of the time
Did you feel worn out? Most of the Time
Did you feel worn out? Some of the Time
Did you feel worn out? A little of the Time
Did you feel worn out? None of the Time
Did you feel full of life? All of the time
Did you feel full of life? Most of the Time
Did you feel full of life? Some of the Time
Did you feel full of life? A little of the Time
Did you feel full of life? None of the Time
No time at all
A small amount of time
Moderate amount of time
Quite a bit of the time
All of the time
I seem to get sick a little easier than other people True or Mostly True
I seem to get sick a little easier than other people Don’t Know
I seem to get sick a little easier than other people False or Mostly False
I am as healthy as anybody I know True or Mostly True
I am as healthy as anybody I know Don’t Know
I am as healthy as anybody I know False or Mostly False
I expect my health to get worse True or Mostly True
I expect my health to get worse Don’t Know
I expect my health to get worse False or Mostly False
My health is excellent True or Mostly True
My health is excellent Don’t Know
My health is excellent False or Mostly False
Male
Female
Diabetes
Osteoarthritis
Blood Pressure
Heart Disease
Lung Disease
Hormone Replacement Therapy
High Cholesterol
Rheumatoid Arthritis
Back Pain
Depression
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO