* Required.
PERSONAL DETAILS
Name *

First

Middle

Last
Title *
Date of Birth *
CONTACT DETAILS
Best Phone Contact *
Street Address *
Suburb *
Postcode *
Email *

We respect your privacy. All information is collected and stored privately. In order to provide you with the highest level of podatric care, there are times when we may need to communicate with your other healthcare providers. If you wish to not receive email communications from Kingsford Podiatry Group (including news and Practice information), please select the unsubscribe button below:

Please tick box if you would NOT like to receive news from Kingsford Podiatry Group

Emergency contact person & phone number *
In case of emergency
MEDICAL DETAILS
Medicare Number *
Patient Number *
Valid to Date *

Please enter Month and Year - example 08-20
Private Health Insurance Details
Please include Name of Fund, Membership Number & Line Number
Veterans Affairs Card Details

Please include Number and whether your card is GOLD or WHITE
General Practioner - Name in Full
Please list your usual GP or the doctor you would attend if medically required
General Practioner Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code
Please list any other Health Care Providers

eg: rheumatologist, endocrinologist, physiotherapist, chiropractor, ostepath
MEDICAL HISTORY
Your Occupation
Sporting pdf-field-1545-Acitvities and Frequency:

Eg: walking 30 minutes daily, weight training twice a week, yoga every day etc
Medical History - please select all that apply
Asthma
Bunion Deformity
Chronic Fatigue Syndrome
Clinical Depression
Diabetes-Type-1
Diabetes-Type-2
Deep Vein Thrombosis / Blood Clot
Epilepsy
Fibromylagia
Hay Fever
Heart Attack
Hepatitis-A
Hepatitis B
Hepatitis C
Hypercholesterolaemia
Hypertension / High Blood Pressure
Hypotension / Low Blood Pressure
Ingrown Toenails
Lesser Toe Deformities
Manic Depression / Bipolar State
Menopausal Symptoms
Morton's Neuroma Pain
Osteoarthritis
Plantar Fasciitis / Heel Spur Pain
Pneumonia
Rheumatoid Arthritis
Stroke
Other Condition(s) / Details of Condition(s)

Please list information regarding any conditions selected including the year you were diagnosed
Please list any medication you take, amount and frequency:
Please list any previous surgical procedures or injuries (including year)
Allergies, sensitivities, dietary restrictions:

eg: Band-Aid blistering, Penicillin skin rash, no gluten etc
Are you a smoker, or have you been a smoker in the past?YseNo
How many per day?
What year did you quit?
Weight

in feet/inches or centimetres
Height
YOUR FOOT HEALTH
Do you wear orthotics or arch supports?YesNo
If 'off-the-shelf', which year fitted?
If Custom-made, which year(s) fitted?

in feet/inches or centimetres
Please select any of the following which describe your current symptoms:
Bunion
Toe pain
Heel arch pain
Joint pain and/or stiffness
Skin lesion, wart, tumour, spot, blister
Ingrowing toenail
Thick or discoloured toenails
Bunionette
Forefoot pain
Midfoot Arthritis
Corns, callus, hard skin
Nerve pain (dull or shooting pain, pins+needles, tingling)
Other Pain (Shin, leg, knee joint, hip joint, lower back)

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.

Accept