what-when-how
In Depth Tutorials and Information
Date:
Name (initials + surname):
Address:
Postal code:
Place of residence:
Telephone:
Date of birth:
Gender:
male female
1.
What is your current
walking capacity
? Choose the most appropriate
answer.
I can walk inside my house (0-10 metres)
I can walk to the neighbour's house (10-50 metres)
I can walk to the corner of the street (50-200 metres)
I can walk to shops etc. in the neighbourhood (200 metres-1 kilometre)
I can walk a fair distance without rest (more than 1 kilometre)
2.
Which of the following
disorders
do you have? (multiple answers are
possible)
diabetes
rheumatoid arthritis
foot disorder (including flat foot, claw toes, hammer toes, bunions)
muscle disease
other, please specify:
3.
Which
specialist
prescribed your orthopaedic shoes?
rehabilitation doctor
orthopaedic surgeon
rheumatologist
other, please specify:
4.
What is the
most important
reason for receiving orthopaedic shoes?
Choose the most appropriate answer.
pain in feet or ankles
wounds/ulcers on the feet
foot disorder
difference in leg length
other, please specify:
Current situation
5.
Indicate the amount of
pain
you feel in the
skin
of your feet and/or ankles
during activities like standing and/or walking.
none very much
6.
Indicate the amount of
pain
you feel in the
muscles and joints
of your feet
and/or ankles during activities like standing and/or walking.
None
very much
