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online questionnaire
Just fill out the questionnaire below and click submit. If any more information is required you will be contacted and if you would like anymre information do not hesitate to contact Orthotics Online via the "ask a question" link above.
Name
*
Address
*
Email Address
*
Telephone Number
*
Gender
*
Male
Female
Age
Weight
Height
Shoe Size
*
1. Are you in pain?
YES
NO
2. If Yes, how long have you had the pain?
1-4 Weeks
1-4 Months
4 Months +
3. Where do you get the pain? (Tick as many boxes as appropriate)
Toes
Left
Right
Ball of Foot
Left
Right
Mid Foot
Left
Right
Heel
Left
Right
Ankle
Left
Right
Lower Leg
Left
Right
Knee
Left
Right
Upper Leg
Left
Right
Hip
Left
Right
Lower Back
Left
Right
4. Can you give more precise details of the pain?
5. What do you think causes the pain?
6. Do you do regular sport/exercise?
Yes
No
7. If you answered Yes, which if the following do you do?
Walking
Running
Football
Rugby
Racket Games
Other
.
8. How much exercise/sport do you do per week?
1-2 hours
2-4 hours
4-8 Hours
8+ Hours
9. If you are a runner what is the average distance you cover per week?
1-5 Miles
5-10 Miles
10-20 Miles
20-30 Miles
30-50 Miles
50+ Miles
10. Have you had previous treatment? (If No, go to question 17)
Yes
No
11. If Yes, who treated you?
GP
Podiatrist
Physiotherapist
Osteopath
Chiropractor
Other
.
12 What treatment did you have?
13. Did the treatment help?
Yes
No
14. Have you had orthoses before? (If No go to question 17)
Yes
No
15. If Yes, did they help?
Yes
No
16. Who prescribed them?
GP
Podiatrist
Physiotherapist
Osteopath
Chiropractor
Other
.
17. When standing, do you perceive your feet as being:
Left Foot
Flat
Normal
High Arched
Right Foot
Flat
Normal
High Arched
18. When NOT bearing weight, do your feet look the same as when standing or have the arches increased?
Left Foot
Same
Increased Slightly
Increased a lot
Right Foot
Same
Increased Slightly
Increased a lot
19. Standing with your feet about 6” (15cm) apart is the distance between your knees compared with the distance between your ankles:
Less
More
Same
20. Still standing in the same position are your knees:
Straight
Pointing inwards a little
Pointing Inwards quite markedly
21. When Pulling your feet up towards your shins (using the ankle joints) is the range of motion the same for both feet? (If Yes go to question 23)
Yes
No
22. Which ankle has the least range of motion?
Left
Right
23. Do You suffer ankle sprains on the outer side?
Yes
No
24. If you answered YES to question 23 which ankle?
Left
Right
Both
25. Have you ever broken an ankle?
Yes
No
26. If YES, which ankle?
Left
Right
Both
28. The Orthoses are designed for use in deep-sided shoes (preferably lace-ups) and trainers. Please indicate the type of shoes in which the Orthoses will be worn:
Lace-up casual shoes
Lace-up formal shows
Lace-up boots
Trainers
29. Please tell us where you heard about Orthotics Online:
After you click Submit you will be redirected back to the home page and a confirmation email will be sent to the email address you supplied.
Note: Further correspondence may be required to give the best quality of service possible. If necessary you will be contacted promptly by Orthotics Online.
www.orthoticsonline.co.uk email: info@orthoticsonline.co.uk, orthotics online, mulberry house, sun hil, royston, herts, SG8 9AU
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