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PATIENT DETAILS FORM

Your General Practitioner

(either private or ancillary)YesNo (If yes, please provide details):



(Enhanced Primary Care) YesNo
(Dept. Veterans Affairs)YesNo
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(claiming under workers compensation) YesNo (If yes, please provide details):

YesNo - (If yes, provide details):

Other Healthcare Practitioners

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MEDICAL HISTORY

Sporting Activities and frequency (e.g. Walking daily, gym classes twice a week, yoga every day etc).

YesNo
YesNo

Medication, including supplements eg. Lipitor 40mg 1 tab at night.

Allergies / dietary restrictions eg. Penicillin allergy, Gluten intolerence etc.

Previous surgery / Other health issues Please include year of surgery/condition.

Have you ever experienced any of the following conditions? Please select all that apply:

StrokeHeart attackDiabetes (type 1/2)AsthmaHypertension (high blood pressure)Hepatitis (A/B/C)FibromyalgiaEpilepsyThyroid DysfunctionHypotension (low blood pressure)OsteoarthritisRheumatoid arthritisHigh cholesterolHeart MurmurDeep vein thrombosis (blood clot)HayfeverMigraineDepression/Anxiety

Please select any of the following which describe your current symptoms:

BunionBunionetteToe PainForefoot_painHeel Arch PainMidfoot ArthritisJoint pain and/or stiffnessCorns, callus, hard skinSkin lesion, wart, tumour, spot, blisterNerve pain (dull or shooting pain, pins+needles, tingling)Ingrowing ToenailOther Pain (Shin, leg, knee joint, hip joint, lower back)Thick or discoloured toenails

APPOINTMENT PREFERENCE:

How did you find out about us?

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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.

By submitting this form, 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.
 

I consent to receiving information via email from Kingsford Podiatry Group. I understand my details are not shared with 3rd parties unless medically required.