PATIENT REGISTRATION FORM

Title *

Given Names *

Surname *

If child (under 18 years) Parent's / Guardian's First Name

If child (under 18 years) Parent's Guardian's Last Name

Address *

Suburb *

State

Postcode *

Date of Birth *

Email Address *

Best Contact Number *

MobileHomeWork

Phone Number *

Alternate Contact Number

MobileHomeWork

Phone number

I want to receive SMS reminders

Occupation *

Health Fund *Enter N/A if none

Family Doctor

Family Doctor's Practice Location

Area of your body to be treated / area of concern *e.g. neck, shoulder, lower back

When did symptoms start? *

What aggravates your condition? *

Symptom Chart

Clear drawing

If you are experiencing pain, is it:

SharpDullComes and goesConstant

Tick all that apply

What makes it better? *

What makes it worse? *

Is your problem

Getting betterGetting worseAbout the same

What are 2 main things you would like to achieve from your appointment?

Activity or exercise. How often do you do these exercises?

Walking

Running

Swimming

Cycling

Gym

Organised sport

HAVE YOU EVER HAD, OR RECEIVED ADVICE OR TREATMENT FOR ANY OF THE FOLLOWING:

Heart condition e.g. previous heart attack, angina, chest pain, rheumatic fever, pacemaker, high cholesterol, high blood sugar *

YesNo

Do you have a family history of heart disease? *

YesNo

Do you have *

High blood pressureLow blood pressureNeither

Do you have *

OsteoporosisOsteopeniaNeither

Do you have *

OsteoarthritisRheumatoid arthritisDegenerative arthritisNone

Cancer, tumour or melanoma *

YesNo

Epilepsy, stroke, paralysis, multiple sclerosis, blackouts or fainting attacks *

YesNo

Asthma, bronchitis, recurrent chest infections, lung condition *

YesNo

Diabetes, pancreatic, hypoglycaemic or thyroid problems *

YesNo

Depression, anxiety, panic attacks, stress or any mental health issue *

YesNo

Have you undergone any operations, surgery, accidents or injuries in the past? *

YesNo

Are you being treated by your doctor for any condition not mentioned already? *

YesNo

Do you have any allergies or have you ever suffered an allergic reaction? *

YesNo

Do you currently smoke? *

YesNo, I quit more than 12 months agoNo, I quit in the last 12 monthsNo, I've never smoked

Have you spent any time in hospital for a medical condition / illness / injury during the last 12 months? *

YesNo

Have you had flu like symptoms within the last 14 days? *

YesNo

Have you been in contact with a confirmed or suspected case of COVID-19 in the last 14 days? *

YesNo

Were you referred / recommended to Performance Podiatry? *

YesNo

Do you provide your consent for your podiatrist to provide medically relevant information to your doctor / specialist / physiotherapist or other allied health practitioner? *

YesNo

I consent to email / letter / SMS promotional offers

This practice operates in accordance with the Privacy Act – please refer to the attached clipboard for further details. (If the patient is younger than 18 years, consent must be provided by a guardian/parent.)

Personal Health information and my health record. May be used and disclosed for the following reasons; for communication with treating medical professionals, for follow up/reminder calls, for discussion with third party insurers, accounting/Medicare/health insurance procedures, disease notifications as required by law, for use by all practitioners to this practice when consulting with you and for legal disclosure as required by a court of law. A full National Privacy Policy is available for your perusal at www.privacy.gov.au

This practice reserves the right to charge a fee for cancellations within 24hrs of your scheduled appointment (50% of appointment fee) and failure to attend without notice (100% of appointment fee). By signing this form and proceeding with treatment you agree to be bound by these terms.

Signature *

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Date

PERFORMANCE PODIATRY

(07) 3846 4800
Suite 2B, 90 Vulture Street
West End, Queensland 4101
www.performancepodiatry.com.au

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