| PATIENT DETAILS |
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| First name* |
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Middle name/s |
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| Preferred name |
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Date of birth |
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| Street Address* |
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Suburb* |
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| Postcode* |
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Home Phone* |
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| Work Phone |
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Mobile |
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| Email |
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Occupation |
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| Next of kin/contact person in an emergency |
| Next of Kin / Contact Person |
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Relationship |
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| Contact Phone |
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| Sporting Activities and frequency (e.g. Walking daily, gym classes twice a week, yoga every day etc) |
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| How did you find out about us? (Please select)*
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| If you selected Other Patient or Health Practitioner, please give their name. If you selected Other, please give details.
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| HEALTH COVER DETAILS |
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(PATIENT NUMBER)-(MEMBERSHIP NUMBER)-(LINE NUMBER) |
Private Health Insurance Company |
| Private Health |
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Are you an EPC (Enhanced Primary Care) Patient?
--- If Yes, please fill out the medicare details below:
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(PATIENT NUMBER)-(MEDICARE NUMBER)-(VALID UNTIL) |
| Medicare |
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Are you a DVA (Department of Veterans Affairs) Patient?
--- If Yes, please fill out the details below:
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| Veterans Affairs Card:
Gold
White
Patient Number:
Card Number:
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Are you a Workcover Patient?
--- If Yes, please fill out the details below:
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| Claim Number: |
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Case Manager: |
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| Contact Number: |
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| General Practitioner |
| Name in Full |
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Clinic Address |
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| Other health care providers |
| Name |
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Name |
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| Profession |
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Profession |
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| Clinic address |
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Clinic address |
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PAST MEDICAL HISTORY
Are you currently or have you been a smoker?*
Yes
No
If so, please fill out the following details where applicable: |
| How many per day? |
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What year did you give up? |
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If you wear foot orthoses/arch supports, what year(s) were these fitted? |
| Preform (off the shelf) insoles |
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Custom-made foot orthoses |
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Please list forms of medication you take, including multivitamins*
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Please list any allergies, sensitivities and/or dietary restrictions (eg. Band-Aids, penicillin, codeine etc)*
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Please list any previous surgical procedures or other significant health problems*
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| Body Weight (kilograms)* |
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Height (feet/inches or centimeters*
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| Shoe size* |
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| Have you ever experienced any of the following conditions? Please select all that apply:
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Stroke |
Heart attack (myocardial infarction) |
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Diabetes I |
Diabetes II |
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Fibromyalgia |
Deep vein thrombosis (blood clot) |
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Hepatitis A |
Hypertension (high blood pressure) |
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Hepatitis B |
Hypotension (low blood pressure) |
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Hepatitis C |
High cholesterol |
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Osteoarthritis |
Rheumatoid arthritis |
| APPOINTMENT REQUEST DETAILS |
| Preferred date (subject to availability) : |
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| Preferred time (subject to availability - please
check clinic times): |
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| At Kingsford Podiatry Group we respect your privacy.
All information collected, is stored securely and accessed only by our staff. In order to provide the highest standard of podiatry care, there are times when we may communicate with your other healthcare providers. |
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I have read the privacy information and I consent to collection and dissemination
of information as described. I understand that provision of my medical history is necessary to provide me with effective, safe and efficient Podiatric management. I have answered all questions to the best of my knowledge. I agree to notify the Podiatrist of any change in my health. |
Click one submit button according to which clinic you would like to visit:
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