Diabetes Foot Health Review Diabetes Foot Health First Name * Last Name * Email * Enter Email Confirm Email * Confirm Email Date of birth * Please use format day/month/year e.g. 12/05/1979 Phone Number * Your Foot Health Please remove your socks and shoes and examine your feet. Do your feet have any of the following signs? Have you noticed any bleeding? * Yes No Is there any new pain in your feet? * Yes No Have you had any liquid or discharge coming out of the foot? * Yes No Are there any cuts or open wounds on your feet? * Yes No Has your foot recently become swollen? Is one foot noticeably bigger than the other foot? * Yes No Have you noticed any odd smell or odour coming from your feet? * Yes No Has your foot recently changed in shape? * Yes No Is there any recent colour change to your feet, in particular, have you noticed any redness? * Yes No Is there anything else about your foot that worries you? * Yes No Please describe what worries you about your foot * Privacy Policy This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. * I consent to the practice collecting and storing my data from this form. Send
