New Patient Questionnaire

New Patient Questionnaire

New patients are always welcome at Ottawa Foot Clinic. We are committed to providing the best quality of care and patient experience to those who bring their nail, foot and ankle problems to our close attention. Please feel free to learn more about our practice and our services if you have not already.A first-time visit to any clinic may be a bit overwhelming: some important information about your health status and specific foot condition(s) may be skipped if the process of filling your intake form is rushed in any way or completed outside your home environment. You will most likely end up with a much better overall examination and results if you make time to get your case very well prepared before your first appointment.  This is why we offer you the option to complete your New Patient Questionnaire way in advance, in the comfort of your home, to provide your foot specialist with a clear and precise picture of your overall case history, specific foot issue(s) over time and, of utmost importance, your goal such as getting:

  • getting back to your game or preferred physical activity by April 15!
  • getting clear nails back on your toes for your next summer vacations!
  • getting rid of your plantar wart before your graduation party!!
  • getting your ingrown toenail fixed as soon as possible!!

The New Patient Questionnaire can be filled out directly online and sent to us in a complete secure way so your privacy is fully protected.

You may as well download the pdf version of the New Patient Questionnaire, print it out and complete it , having all necessary information at hands. You may then email it, fax it or bring it with you at the time of your first appointment. This will save you 15 minutes upon arrival, especially if you intend to arriving right on time – yes, we know how tight is your schedule is! Plus it will give your foot specialist the very valuable opportunity to review your questionnaire in advance in order to get  prepared to serve you the best possible way, namely in getting to the point much faster, with much more clarity!

If you have any further questions about what you may expect during your first visit at Ottawa Foot Clinic, please call us at (613) 595-9700.

PDF Download

OttawaFootClinic - New Patient Questionnaire













Parent name (if under 18 year-old), guardian name or primary care name and phone number


Emergency Contact Name and phone number



If you would like your family doctor to receive a report of your consultation this information must be completely correctly.









Percentage of time at work




Percentage of time at home









YesNo

YesNo
I wear my current orthotics


Health Summary


YesNo

YesNo

YesNo

YesNo


ExcellentGoodAveragePoor

YesNoThere may be a possibility

AnemiaAsthmaAdhesive TapePoor CirculationRheumatic FeverShortness of BreathErythromycinGoutTylenolDiabetesDifficulty HealingLiver ProblemPhlebitisAspirin (ASA)CodeineHeart ProblemsHigh Blood PressureUlcersCancerNovocainCortisoneKidney ProblemsPenicillinSulphaEpilepsyHepatitis


YesNo

YesNo

YesNo

YesNo


YesNo


I hereby give my permission to Antoun Hajj, Doctor of Podiatry Medicine / Registered Chiropodist to examine and treat my feet medically, surgically or orthopedically. I acknowledge that fees for services are not covered by OHIP and are payable each treatment session. I also acknowledge the required reschedule or cancellation policy of two business day notice to avoid an office charge. Missed appointments will also be charged in full for the scheduled service reserved.

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