Foot Health Status Questionnaire

June 11, 2011

Name: _______________

Date of Birth: _______________

Sex: __________________

Address: _________________

Q1. How often do you clean your feet?

Q2. Do you feel any sort of pain when you are walking, running, jogging or exercising?

Q3. Do you have a history of pain in any of your feet?

Q4. Did you ever injured your feet or ever met with an accident that had hurt your feet?

Q5. What is the shoe size that you usually wear?

Q6. Does the shoe that you wear fit you properly?

Q7. Do you wear high heel shoes?

Q8.  If you do wear high heel shoes, does it fit you properly?

Q9. Do you have heel spur?

Q10. Has anyone in your family got history of heel spur?

Q11. Did you ever had fungal infection of the skin that causes scaling, flaking, and itching at the affected areas (athlete’s foot)?

Q12.  Have you ever suffered from callus disease?

Q13. Is there any formation of toughened area of skin which has become relatively thick and hard in response to repeated friction, pressure, or other irritation?

Q14. Is there a history of any of your family members suffering from any kind of fungal disease in the feet?

Download Foot Health Status Questionnaire in Word Format

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