Surgical Patient Details

Title *
Last Name *
First Name *
Middle Names
Preferred Name
Date of Birth (dd/mm/yyyy) *
Street Address *
Suburb/Town *
Postcode *
Home Phone *
Work Phone
Mobile
Your Email *
Occupation
Next of kin/contact person in an emergency
Next of Kin
Relationship
Phone
Your General Practitioner
Full name
Clinic Address
Clinic Phone
Do you have private health cover? (either private or ancillary) YesNo - (If yes, please provide details):
Insurance Co.
Membership/Line No.
Medicare No. (Card No, Line No, Expiry Month, Year)
- - -
Are you an EPC Patient?
(Enhanced Primary Care) YesNo
Are you a DVA patient? (Dept. Veterans Affairs) YesNo
If yes: Gold CardWhite Card
Patient No:   Card No:
Are you a Workcover patient? (claiming under workers compensation) YesNo - (If yes, please provide details):
Employer Name:
WorkCover Insurance Company:
Claim Number:
Date of Injury (dd/mm/yyyy):
Case Manager:
Contact No:
Are you covered under the TAC (Transport Accident Commission) from a motor vehicle accident? YesNo - (If yes, provide details):
Claim Number:
Date of Injury (dd/mm/yyyy):
Case Manager:
Contact No:
Sporting Activities and frequency (e.g. Walking daily, gym classes twice a week, yoga every day etc).
How did you find out about us?
Name:
Profession:
Clinic Address:
Name:
Profession:
Clinic Address:
Name:
Profession:
Clinic Address:
Name:
Profession:
Clinic Address:
Have you ever smoked? YesNo
How many per day?
What year did you quit?
Do you wear foot orthoses/arch supports? YesNo
If 'off-the-shelf', which year fitted?
If Custom-made, which year(s) fitted?
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.
Body Weight (kg):   Height ('/" or cm):   Shoe size (US):
Have you ever experienced any of the following conditions? Please select all that apply:
Stroke
Heart attack
Diabetes (type 1/2)
Asthma
Hypertension (high blood pressure)
Hepatitis (A/B/C)
Fibromyalgia
Epilepsy
Thyroid Dysfunction
Hypotension (low blood pressure)
Osteoarthritis
Rheumatoid arthritis
High cholesterol
Heart Murmur
Deep vein thrombosis (blood clot)
Hayfever
Migraine
Depression/Anxiety
Please select any of the following which describe your current symptoms:
Bunion
Bunionette
Toe Pain
Forefoot_pain
Heel Arch Pain
Midfoot Arthritis
Joint pain and/or stiffness
Corns, callus, hard skin
Skin lesion, wart, tumour, spot, blister
Nerve pain (dull or shooting pain, pins+needles, tingling)
Ingrowing Toenail
Other Pain (Shin, leg, knee joint, hip joint, lower back)
Thick or discoloured toenails
Appointment Request:
Preferred Date (dd/mm/yyyy)
Preferred Time (00:00am)

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.

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.