1. Male or Female?

• Male
• Female

2. Age?

3. How long have you been noticing the discolouration of the toenail?

• Less than 1 year
• 1-3 years
• 5 years plus

4. What percentage of the toe nail is affected?

• 25%
• 50%
• 75%
• 100%

5. Have you noticed any change to nail bed or any discharge emitting from the nail bed?

• Yes
• No

6. Do you play sport regularly or are you a runner?

• Yes
• No

7. Have you tried using alternative treatments?

• Yes
• No

8. What are your most common footwear practices?

• Boots
• Shoes
• High Heels
• High Tops
• Trainers
• Thongs

9. Is this condition common in your family?

• Yes
• No

10. Have you consulted a podiatrist before?

• Yes
• No

11. Have you been prescribed Oral or Topical Antifungals by your GP in the past?

• Yes
• No

12. Do you have any known allergic reactions?

• Yes
• No

13. Are you diabetic?

• Yes
• No

14. Are you on any other medications?

• Yes
• No

15. Do you have any further health concerns that could compromise your immune system?

• Yes
• No

16. Please attach pictures of your nail concern for our podiatrists to assess.

17. Is the information provided accurate to the best of your knowledge? This will help us identify the best course of treatment

• Yes
• No

Please advise what day and time would be suitable for a video or phone consultation.

• Phone
• Video

Thank you very much, our MNHFP podiatrist will be reviewing your information and we will be in contact with you shortly or please contact us now on 1800 880 160 or 0800 020 055 to discuss right away. Regards MNHFP Client Service Team.

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