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 *
Patient Name *
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?
Can you read English? *
Can you write English? *
Do you hear well? *
If no, do you utilize a hearing device?
Clear selection
Do you see well? *
If no, do you utilize glasses or contact lenses?
Clear selection
Do you have cultural or religious beliefs that may affect your care/ treatment? *
If yes, please explain
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