NEW PATIENT & MEDICAL HISTORY FORM
Personal & Contact Information
Full Name
Prefix
First Name
Last Name
DOB
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Day
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Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State
Postal Code
Phone Number
E-mail
Occupation
Emergency Contact Name
Emergency Contact Number
Name of GP
Do you have Private Health Insurance (including podiatry cover)?
Yes
No
If Yes which Health Fund?
How did you hear about our clinic?
Google Search
Word of mouth
Walking past
Referral
Other
Referred by (if relevant):
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Medical History
Please select if you currently or have previously suffered from the following conditions:
Diabetes
Poor feet blood flow
Loss of feeling in feet
HIV / AIDS
Hepatitis
Osteoporosis
Cancer
Blood clots
Gout
Rheumatoid Arthritis
Osteoarthritis
Depression
Other
Please list any regular medications
Please list any allergies
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Foot / Leg History
What is the purpose of your visit today?
Have you seen a Podiatrist or other health professional for this issue previously?
Yes
No
Are you able to comfortably stand and walk for +30 minutes?
Yes
No
Are you able to comfortably perform your work or home duties?
Yes
No
Please list any regular activities or sports you participate in?
Privacy Statement:
Recent requirements under the Health Privacy Act state that we now require your consent to collect information about you. We require you to provide us with your personal details and a full medical history, so that we may properly assess, diagnose, treat and be proactive in your health care needs. This means we will use the information you provide in the following ways: • Administration purposes in running our practice • Billing purposes, including compliance with Health Insurance Commission requirements • Relating your information to others involved in your care, including your general practitioner and specialists outside this practice. This may occur through referral to other doctors or for medical tests. • Occasional marketing emails notifying existing patients of special offers or changes at the practice. Please let us know if you do not want your records accessed for these purposes and we will note this in your record accordingly. If you consent to the handling of your information for the purposes set out above, please sign and date below.
Signature
Date
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Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
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