DOSSIER MÉDICAL PODIATRIQUE FICHE D'INFORMATION Nr.

____

Nom complet : _______________________________________________________________________________Sexo:________

Address : ____________________________________________________________________________________________
Phone : __________________________Birth:____________________________ Age:_____________________
Occupation :____________________________________________________________________________________________
Centro de derivación:__________________________________________________________________________________________

Maladie dont il souffre :

XD HTA Arthrite Arthrose Ostéopr Autre:__________________________________
Medicines :___________________________________________________________________________________________
SYMBOLOGIE Poids : _______kilos

Hauteur :_______mt

N° chaussures :________

EXAMEN DES PIEDS

IMPULSION DE LA PÉDALE
(+) (-)

Droite Gauche

POULS TIBIAL (+) (-)

Droite Gauche

TEMPERATURE

Norme froide Norme chaude

PROBLÈMES CIRCULATOIRES

Oui Non

PEAU

REMARQUES : TRAITEMENT: INDICATIONS :

___________________________
ASEPSIA ___________________________
Adéquat Inadéquat Très inadéquat Chaussures PROMOTION ___________________________
_____________________________________________ NETTOYAGE DES RAINURES ___________________________
_____________________________________________ ________________________
_____________________________________________ ONYCOTOMY ________________________
_____________________________________________ DISPARAGEMENT ________________________
_____________________________________________ RESECADO ________________________
_________________________________________________
HELOTOMIE ________________________
___________________________________________ ROUGHING ________________________
___________________________________________ PULIDO ________________________
___________________________________________ ASEPSIS FINALE ________________________
___________________________________________ AUTRES: ________________________
____________________________________________________________________________ ________________________
____________________________________________________________________________ ________________________
____________________________________________________________________________
___________________________________________ _________________________________ DATE :____/____/________
___________________________________________ _________________________________
__________________________________________ _________________________________ CONCESSIONNAIRE :
__________________________________________ _________________________________
__________________________________________ _________________________________
__________________________________________