New patient intake

Tell me a little about your health.

This short form helps me prepare for your visit and tailor care to you. It's optional — you can also fill it out at the appointment.

Your privacy matters. This form runs entirely in your browser — nothing is sent over the internet. When you click Print / Save as PDF, your answers stay on your device. Bring the printout to your appointment, or save it as a PDF and hand it to me at your visit.

About you

Basic information so I know who I'm seeing.

Medical history

Any current conditions, past illnesses, allergies, or medications worth noting.

Include current conditions, past illnesses, allergies, and current medications.

Any past surgeries, with approximate dates if you recall them.

Conditions affecting foot care

These help me adjust my technique and watch for specific risks.

For example: warfarin, Eliquis, Xarelto, Plavix, aspirin therapy, etc.

Numbness, tingling, or reduced ability to feel touch or temperature.

Your foot care

A bit about what's going on with your feet and any current care.

For example: ingrown nails, thick or painful nails, calluses, dry skin, swelling, cracks, sores, or anything that's been bothering you.

Need to book your visit? Schedule an appointment →