1. Do your feet hurt? Do you live with constant foot pain? Do you regularly take aspirin, ibuprofen, or any other medication for pain in your feet?
   Yes No
2. Does it bother you when you walk or run?
   Yes No
3. Are you tired of pain and discomfort in your feet? Do your shoes bother you, often?
   Yes No
4. Do you have toenail infections? Toe or joint deformities? Heel pain? Growths of bone on the underside and forepart of your heel? Toenails that dig painfully into the corners of your skin?
   Yes No
5. Do you have arthritis, gout, diabetes, or circulatory problems? Are you noticing problems with your feet?
   Yes No
6. Do you have foot infections (including athlete's foot, other fungal infections, and warts)?
   Yes No
7. Do you have corns on your feet? Calluses? Bunions? Any unusual bumps, growths or hardened spots? Thick, dead layers of skin on your feet? Any enlarged growths between your third and forth toe? Is your toe bent in a claw-like position?
   Yes No
8. Do you regularly wear high-heels, narrow shoes or other "uncomfortable" shoes?
   Yes No
9. Are you overweight and have pain in your feet?
   Yes No
10. Are you suffering from a painful, inflamed swelling at the first joint of the big toe?
    Yes No
11. Are you currently suffering from a foot or ankle injury, possibly a break, sprain or strain of the ankle or feet?
    Yes No
12. Are you currently suffering from an acute attack of pain in your big toe? Are you a male over 30 that has serious pain in the joints lasting more than a day or two? Do you also have a family history of gout? Do you think you may have gout?
    Yes No
13. Do you have any sores on your feet that will not heal? Are you diabetic, at risk for diabetes, or have a family history of diabetes? Do you have tingling, numbness and/or pain in your lower legs?
    Yes No

Sources

Buist AS, Petty TL, Widemann HP. COPD: Don?t wait until it?s  obvious. Patient Care. 1991;25:60-85.

Muir Bernice. Pathophysiology: An introduction to the mechanismsof disease. 1988. Wiley Medical, USA.