Patient paperwork, at your pace.

Welcome · Source page 1

Welcome to Sole Sanctuary Podiatry

Your foundation for moving forward.

Welcome to Sole Sanctuary Podiatry. Thank you for choosing us and allowing us to be part of your

healthcare journey.

We believe that meaningful care begins with listening, understanding, and creating an environment where

you feel safe, respected, and supported.

Your feet are your foundation. They connect you to the ground, provide essential information for balance

and movement, and help carry you through the experiences that make your life meaningful.

When pain, injury, instability, or limitations interfere with your ability to move comfortably and confidently,

the effects can extend far beyond your feet.

Our approach recognizes that you are more than a diagnosis or a collection of symptoms. Your experiences,

concerns, aspirations, and goals are essential to understanding how we can best support you.

Through thoughtful examination, clinical expertise, education, and individualized care, we will work together

to identify opportunities to improve your mobility, function, and overall well-being.

We value curiosity, honest communication, and collaboration. We encourage your questions and welcome

your participation in decisions about your health.

Above all, we want Sole Sanctuary to be a place where you feel at peace, knowing that you will be heard,

treated with compassion, and supported in finding your way forward.

Our goal is simple: to help you build the stability, confidence, and freedom to participate more fully in the

life you wish to live.

We look forward to getting to know you.

With warm regards,

Lorelei C. Achor, DPM, DABPM

Sole Sanctuary Podiatry

949-528-8558 info@solesanctuarypodiatry.com

Intake · Source page 1

NEW PATIENT INFORMATION

Comprehensive Patient Intake

Self Pay Care

We want to understand your health history, how you move, and what matters to you. Your answers will help us

plan care around your needs and goals.

Complete what you can. Write “none,” “not sure,” or “prefer to discuss” where helpful. You may attach medication lists and

additional pages. Ask for assistance if needed.

Getting to Know You

Legal name

Preferred name Date of birth Date

Pronouns optional Occupation or daily role

Address

City State ZIP

Phone Email

Preferred language Interpreter needed Yes No

Emergency contact Relationship

Emergency contact phone

Primary care clinician Phone

Other clinicians involved in this concern

How did you hear about us

Your Priorities

What brings you here now? What is your most important concern?

What would you like your health and mobility to make possible in your life?

Do you need help with forms, hearing, vision, mobility, or communication?

Contact details above do not authorize medical information to be sent by text or email. Communication preferences and permissions are

documented separately.

Intake · Source page 2

PATIENT INTAKE

Your Current Concern

Patient name Date of birth

Describe the problem in your own words. Where is it located?

Side Right Left Both Other Start date

Onset Sudden Gradual After injury or surgery Unsure

Course Improving Worsening Unchanged Comes and goes

What was happening when it began? Was there an injury, illness, or change in activity?

Symptoms Pain Swelling Stiffness Burning Tingling Numbness

Weakness Instability Skin or nail change Wound Other

Pain over the past week 0 = no pain | 10 = worst pain imaginable

Current /10 Average /10 Worst /10 No pain

Pattern First steps Standing Walking At rest At night Other

What makes symptoms worse? What helps?

Earlier Evaluation and Treatment

Include shoes, orthotics, braces, therapy, exercises, medication, injections, surgery, and other care. Attach reports if

available.

Treatment or test and date Result or benefit How long it helped

Have you ever felt “I have never been the same since…”? Please explain if relevant.

What explanation or diagnosis have you been given? What remains unanswered?

Intake · Source page 3

PATIENT INTAKE

Your Health History

Patient name Date of birth

Check conditions you have now or have had in the past. Add details below, including dates and whether a condition is active,

resolved, or uncertain.

Medical Conditions

Diabetes Prediabetes Thyroid disorder Osteoporosis Kidney disease

High blood pressure Heart disease Stroke or TIA Poor circulation

Blood clot Bleeding disorder Leg swelling Lung disease or asthma

Sleep apnea Liver disease Digestive condition Cancer

Arthritis Gout Autoimmune condition Frequent or serious infections

Neuropathy Neurologic condition Seizures Fainting or dizziness

Depression Anxiety Chronic pain Skin condition Slow wound healing

Other None known Prefer to discuss

Please explain checked conditions, important dates, and current treatment.

If known A1c Date Height Weight Recent change

Pregnant, possibly pregnant, or breastfeeding Yes No Not applicable

Symptoms to Discuss

Mark symptoms that are new, ongoing, or unexplained. This form is reviewed during your visit; it is not monitored for urgent

concerns.

Fever Unexplained weight change Fatigue Chest discomfort

Shortness of breath Calf pain with walking Foot pain at rest

Cold or discolored feet Open wound New weakness or loss of sensation

Back or neck pain Joint pain or stiffness Headaches Vision changes

Bladder or bowel changes Balance changes Other

Describe symptoms, when they started, and whether another clinician evaluated them.

Family Health History

List relevant conditions in close relatives, such as diabetes, neuropathy, circulation problems, arthritis, clotting

disorders, or inherited conditions. Include the relationship.

Intake · Source page 4

PATIENT INTAKE

Medications Allergies and Procedures

Patient name Date of birth

Medications and Supplements

List prescriptions, nonprescription medicines, supplements, herbs, cannabis, creams, and drops. You may attach a list or

photo.

List attached No medicines or supplements

Name and strength Dose and frequency Reason or prescriber

Blood thinner or daily aspirin Steroid or immune medicine

Recent medication changes or side effects

Preferred pharmacy Phone

Allergies and Reactions

No known allergies Not sure

Include medicines, latex, adhesives, skin preparations, and other relevant substances. Describe the reaction rather than only

naming the substance.

Substance Reaction and approximate date

Surgeries Hospitalizations and Major Injuries

Include side or body area, date, complications, and recovery concerns.

Procedure injury or admission Date and side Recovery or complications

Any problems with anesthesia, postoperative infection, healing, or persistent pain?

Upcoming surgery or procedure Date

Surgeon Current restrictions

Intake · Source page 5

PATIENT INTAKE

Movement Function and Foot History

Patient name Date of birth

Everyday Movement

Comfortable walking time min Standing time min Sitting time min

Difficulty with Stairs Uneven ground Squatting Getting up from a chair

Dressing Driving Work Exercise Household tasks Other

Mobility aid None Cane Walker Wheelchair Other

Describe a usual day of movement, exercise, work, or caregiving. What has changed?

Balance and Sensation

Falls in the past 12 months Near falls Injuries from a fall

Fear of falling Dizziness Trouble sensing the ground Foot catching or dragging

When do you feel unsteady? Do you notice weakness, altered sensation, or coordination?

Foot Ankle and Related History

Sprains Fractures Tendon injury Plantar fasciitis or heel pain

Bunions or toe deformity Flat or high arches Toe walking or intoeing

Nail problems Calluses Wounds or ulcers Foot or ankle surgery

Hip or knee symptoms Back symptoms Joint replacement Other

Add dates, side, repeated injuries, and previous treatments or restrictions.

Shoes and Supports

Usual shoe types Size Width Hours worn

Supports None Store bought insert Custom orthotic Brace Other

Which shoes or supports help? Which worsen symptoms? Any recent footwear changes?

Are there movements or activities you avoid? What concerns you about doing them?

Intake · Source page 6

PATIENT INTAKE

Daily Life Recovery and Care Preferences

Patient name Date of birth

Sleep Energy and Recovery

Sleep per night hours Sleep quality Restful Variable Poor

Symptoms interrupt sleep Snoring Daytime sleepiness Shift work

Energy 0 = no energy | 10 = your usual best energy Current energy /10

What restores you? What makes rest or recovery difficult?

Nutrition and Habits

Describe your usual eating pattern, hydration, and any dietary needs or restrictions.

Nicotine or tobacco Never Former Current Type and amount

Alcohol drinks per week Cannabis or other substances

Anything affecting appetite, nutrition, or access to food

Stress Support and Practical Needs

Stress 0 = none | 10 = overwhelming Current stress /10

What responsibilities, life changes, or practical barriers affect your care or recovery?

Who can help if needed

Possible barriers Time Cost Transportation Caregiving Work demands

Difficulty following a plan Limited support Other

Care Preferences

What has helped you feel heard and safe in healthcare? What would you like done differently?

Care priorities to discuss Understanding my symptoms Movement and footwear

Recovery habits Home care Understanding treatment options

Prefer to discuss in person Other

Any beliefs, cultural needs, touch preferences, or experiences you want us to consider?

These optional answers express preferences and do not provide consent for a treatment. You may leave sensitive questions blank and

discuss them privately.

Intake · Source page 7

PATIENT INTAKE

Your Goals and Meaningful Activities

Patient name Date of birth

What would a successful outcome look like to you?

Why does this matter now? What would you most like to return to or begin?

Three Activities You Want to Regain

Patient Specific Functional Scale activity record

Choose three important activities limited by your current problem. Be specific, such as walking the dog for 20 minutes or

standing long enough to prepare dinner. Rate your current ability for each.

0 = cannot do the activity | 10 = can do it at your level before this problem

Activity and usual duration or demand Why it matters

If the problem has always been present or you cannot identify a prior level, leave the score blank and discuss an appropriate measure with

your physician.

Activity you most want to prioritize

Desired timeframe or important upcoming event

Readiness and Shared Planning

Confidence in following a plan 0 = none | 10 = very confident /10

What would increase your confidence? What concerns or limitations should we plan around?

What is one realistic step you would feel ready to take?

What have we not asked that you would like us to understand?

Completed by Patient Patient with assistance Representative

If assisted Name Relationship

Patient or representative signature ____________________________ Sign by hand after printing Date

I completed this history to the best of my knowledge. This confirms history only; agreements are separate.

Media · Source page 1

Informed Consent for Educational

Photographs and Recordings

Practice: Sole Sanctuary Podiatry

Clinician: Lorelei C. Achor, DPM, DABPM

Patient name:

Date of birth:

Participation is voluntary. Read all three pages. Check only the items

you allow. Unmarked boxes are not authorized.

1. Materials and purpose

I authorize Sole Sanctuary Podiatry and its clinicians and staff to create,

use, and disclose only the materials selected below for the educational

uses I approve on page 2.

Photographs

Video (sound also requires audio permission below)

Audio recordings, including sound with video

Clinical images, such as X-rays or ultrasound

Brief case details about the condition, care, and results specified below

Body area and condition or procedure:

Capture period: Selected materials created during my care with Sole Sanctuary Podiatry while this authorization is in effect.

Earlier materials to include (optional; dates if known):

The purpose is to teach about health conditions, procedures, care

techniques, and treatment results. My full medical record is not included.

Media · Source page 2

Educational Uses and Privacy Choices

Patient name:

I may ask for recording to stop at any time. This form does not authorize

an additional medical procedure. No personal medical benefit or payment

is promised.

My decision will not affect treatment, payment, health-plan enrollment, or

eligibility for benefits. I may decline any selection or decline to sign.

2. Teaching audiences and uses

Check each setting you allow. Permission includes repeated use during the

authorization period. Authorized recipients may use the materials only for

the selected educational purposes and within my stated limits.

Internal teaching: practice clinicians, staff, and supervised fellows,

residents, students, and trainees.

Professional teaching: healthcare professionals and students,

including educators and meeting organizers, at restricted-access

classes, conferences, and courses, including secure online courses.

Optional limits on organizations or events:

This form does not authorize advertising, marketing, social media posts,

sale of my health information, or research.

3. Identity and additional limits

The practice will remove my name, birth date, contact details, and record

numbers from teaching copies. It will avoid or obscure my face,

recognizable voice, and other identifying features unless I specifically

allow them below. Identification may still be possible from clinical details

or images.

Optional recognizable features I allow:

Face

Voice (also select audio permission on page 1)

Other body feature:

Other limits or requests:

Media · Source page 3

Withdrawal, Duration, and Authorization

Patient name:

4. Privacy and withdrawal

Disclosed materials may be copied or shared again and may no longer be

protected by HIPAA. California law may still restrict further disclosure.

I may revoke this authorization at any time by delivering or mailing a

written request to the contact below. Revocation stops future recording,

use, and disclosure by the practice, except for actions already taken in

reliance on this authorization. The practice cannot undo a completed

presentation or retrieve every distributed copy.

Privacy contact or office manager: Lorelei C. Achor, DPM, DABPM

Mailing address: 24953 Paseo de Valencia, Bldg C, Suite 15C
Laguna Hills, CA 92653

Phone for questions and copies: 949-528-8558

Email: info@solesanctuarypodiatry.com

5. Patient-requested duration and signature

I request authorization through the specific date below, including repeated

use in permitted future presentations. If the date is more than one year

after I sign, I specifically request that longer period. I may choose a shorter

period.

Requested expiration date:

Initials:

Enter a specific calendar date and initial before signing. I have a

right to a signed copy, which will be provided. I may request additional

copies using the contact above.

I have read this form or had it explained to me. My questions have been

answered. My signature authorizes only the selections and limits recorded

on all three pages.

Patient or representative signature: ____________________________ Sign by hand after printing

Date signed:

Printed name:

Representative relationship and authority:

Signed copy provided on / Staff initials: To be completed by the practice before use.