Got a Foot Problem?

By filling out this questionnaire, we can better help you find the products and information for your specific footcare needs. Please answer the following questions and symptoms that seem to be of concern.
Yes   1. Are you a Diabetic?
Yes   2. Do you have tenderness or pain in any of the following areas?
(Check all that apply...)
Mid Toes
Little Toes
Big Toes
Forefoot
Arches
Knees
Shin
Heel
Ankle
Big toe pain Middle toe pain Little Toe pain
Forefoot pain
Knee pain
Arch pain
Shin pain
Heel pain
Top of foot pain Ankle pain
Yes   3. Are you currently being treated by a Podiatrist?
Yes    4. Would you like a referral to a Podiatrist in your area?
    Please enter your Zip Code:
    
Yes    5. Have you ever worn, or do you currently wear orthotics?
Yes    6. Do you have foot odor?
Yes    7. Are your toenails thick, brittle, tingly or painful?
Yes    8. Do you have corns or calluses?
Yes    9. Do you have dry, scaley, itchy skin?
Yes    10. Do you have any foot injuries?
Yes    11. Do your feet burn?
Yes    12. Do you have warts?
Yes    13. Do you have flat feet?
Name:
Email:
Yes    Yes, please sign me up for the FootWeb newsletters!



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