Forms for New Patients

DIABETIC QUESTIONNAIRE
At Twin Cities Foot and Ankle Clinic, we believe your time is valuable. That’s why we work hard to ensure that each of our appointments begins on time.
To facilitate this promptness, we ask that you complete a few essential forms prior to your visit. The information you provide in these forms helps us to better understand your situation and the symptoms you are presenting, which will aid in creating a care plan that is customized to your needs.
Having them completed beforehand also allows you the opportunity to contemplate each question and provide an accurate and thorough response, which will save time during your office visit.

FILL OUT THE FORM BELOW OR CLICK HERE FOR A PRINTABLE DIABETIC QUESTIONNAIRE FORM

Diabetic Questionnaire (for diabetics only)

Please fill out below and then SEND.

  • Date of Birth MM/DD/YYYY

  • Blood Sugar

    How often do you or someone else check your blood sugar?

  • Sores

    Do you have a history of foot sores that do not heal? If yes, which foot?

  • Sensation

    Do you have any loss of sensation in your feet or toes, including burning, tingling, and/or numbness?

  • Hospitalization or Surgery

    Have you been hospitalized or had surgery in the last five years for a condition related to your diabetes?

  • Diabetic Specialist

    Do you see a diabetic specialist?

  • Date you were last seen?

  • Foot Specialist

    Other than this office, have you ever seen a foot specialist?

  • Date you were last seen?

  • Shoes

    Have you ever owned diabetic shoes prescribed by a physician?

  • Date you were last seen?

Golden Valley

Dr. Felton | Podiatrist
Dr. Felton
Dr. Sperling | Podiatrist
Dr. Sperling

CONTACT US

Office: 763-546-1718
Fax: 763-546-1943
Email: info@tcfoot.com

GOLDEN VALLEY

5851 Duluth St., Ste 101
Golden Valley MN, 55422

GENERAL OFFICE HOURS

Monday – Thursday
8:30 a.m. – 5:00 p.m.
Friday
8:30 a.m. – 12:30 p.m.

APPOINTMENT HOURS

Monday – Thursday
9:00 a.m. – 4:30 p.m.