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.
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
Required
Do you speak English in your home? *
If no, what language do you speak? Name of interpreter?
Your answer
Can you read English? *
Can you write English? *
Do you hear well? *
If no, do you utilize a hearing device?
Do you see well? *
If no, do you utilize glasses or contact lenses?
Do you have cultural or religious beliefs that may affect your care/ treatment? *
If yes, please explain
Your answer
Other comments
Your answer
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