Footcare Direct - Ask the Foot Doctor!

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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

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 City & State:
City:
State:

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:
City/State: