Podiatry Consult Letter Template November 26, 2025

Demographics

RE: [patient name] DOB: [date] Dear Dr. [referring physician name], Thank you for referring [patient name] to our office for evaluation.

Chief Complaint

Medical Note Template -- [Chief Complaint]

History of present illness

Provide a thorough, well organized summary of the patient's condition, including onset, duration, and any relevant details. If diabetic and we talk about diabetic issues organize into diabetic history include summary of a1c , diabetic history, neuropathy, ulcerations, PVD. If we talk about 2-3 problems organize them separately.

Past medical history

[Include any past medical history or chronic illnesses.]

Past surgical history

[Include any surgical history.]

Current medications

[List current medications including medication name, dose, frequency, route, and duration.]

Allergies

[List any known allergies or state if none.]

Social history

- Occupation: [Insert occupation] - Recreational activities: [Insert recreational activities] - Smoking: [Insert smoking status] - Alcohol use: [Insert alcohol use] - Recreational drug use: [Insert recreational drug use] - Footwear: [Describe footwear] -Orthotics:[Descibe past and current orthotics and usage and any use of over the counter devices and include how old they are and response]

Podiatric medical exam

- Height: [Insert height] - Weight: [Insert weight] -BMI:[insert BMI} - Shoe size: [Insert shoe size]

Vascular

- Right: - Popliteal: [Insert value] - DP: [Insert value] - PT: [Insert value] - Capillary refill time: [Insert value] - Digital hair: [Present/absent] - Left: - Popliteal: [Insert value] - DP: [Insert value] - PT: [Insert value] - Capillary refill time: [Insert value] - Digital hair: [Present/absent] Include functional history if we talk about how much the patient can walk and if there is any claudication or rest pain

Neurological

- Vibratory sensation: [Intact/impaired] - 10g monofilament: [Insert value] - Tinel's sign: [Positive/negative] - Mulder's click: [Positive/negative]

Musculoskeletal/biomechanical

-Include pertinent non-weight bearing findings that are MSK/Ortho related: - Pain-free on external and internal rotation of the hips. - Pain-free on range of motion of bilateral knees. - Ankle joint dorsiflexion to perpendicular with the knee extended and [insert value] degrees with the knee flexed. - Subtalar joints are pain-free with [insert value] inversion and [insert value] eversion. - Midtarsal joints are pain-free bilaterally. - [Insert value] forefoot valgus bilaterally. - Hallux limitus with reduced dorsiflexion to less than [insert value] degrees with the forefoot loaded and [insert value] degrees with the forefoot unloaded. - Mild contractures of the lesser toes noted. Weight bearing exam: - [insert value for if they are standing pes planus or cavus foot] - RCSP of R foot: [Insert value] degrees with [insert value] toes in the transverse plane RCPs of L foot [insert value] degrees with [insert value] with toes in the transverse plane - NCSP: [Insert value] bilaterally. - Double toe rise: [Description of findings]. - Single toe rise: [Description of findings]. - Gait analysis: [Description of findings].

Dermatological

- Calluses: [Description and location] - Nails: [Description and location] - Skin: [Description]

Footwear

[Description of footwear]

Orthotics/insoles

[Description of orthotics ]

X-rays

[Description]

Assessment and plan

Impression: [Insert diagnosis] Treatment plan/discussion: We reviewed the surgical and non-surgical options. The potential risks and complications of surgery, including but not limited to post-operative infection, delayed or non-healing, complex regional pain syndrome, swelling, and deep vein thrombosis, were discussed. No guarantees can be provided. The patient consented to surgery, which will be scheduled upon availability. Sincerely Ian Yu DPM FACFAS DABPS MSc Fellow of the American College of Foot and Ankle Surgeons Diplomate of the American Board of Podiatric Surgery Masters of Science in Medical Education Board Certified in Foot Surgery Certificate in AI in Healthcare Harvard Medical School

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