Initial Learning Assessment
During your visit with our organization you will be presented with information that may
be new to you. To aid in providing the best care possible please answer the following
questions. Thank You.
* Required
Manhattan Podiatry Associate Doctor
*
Your answer
Patient Name
*
Your answer
Date
*
MM
/
DD
/
YYYY
How do you like learning new things?
*
Check all that apply
Reading
Discussion
Pictures/Diagrams
Hands on Demonstration
Self-Study
Other:
Required
Do you speak English in your home?
*
Yes
No
If no, what language do you speak? Name of interpreter?
Your answer
Can you read English?
*
Yes
No
Can you write English?
*
Yes
No
Do you hear well?
*
Yes
No
If no, do you utilize a hearing device?
Yes
No
Clear selection
Do you see well?
*
Yes
No
If no, do you utilize glasses or contact lenses?
Yes
No
Clear selection
Do you have cultural or religious beliefs that may affect your care/ treatment?
*
Yes
No
If yes, please explain
Your answer
Other comments
Your answer
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