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44 Manning Rd, Aberfoyle Park SA 5159

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New Patient Form

Prior to your first appointment, we'll need a few details from you. Please complete the form below and click 'Submit' to send through your information. Alternatively, you can print the completed form and bring it with you to your first appointment.

Contact Information

First name

Surname

Email

Street Address

Suburb

Postcode

State

Phone Number

Private Health Insurance

Do you have Private Health Insurance?

Yes No

If yes, which Health Fund do you belong to?

Concession Card Holders

Do you hold a valid concession card?

Yes No

What type?

Card number

Major Complaint

What is your main problem?

How and when did it start?

What relieves your symptoms?

What makes them worse?

Does it wake you from sleep?

Yes No

Does your current problem involve any of the following:

Pain in either arm or leg

Tingling in either arm or leg

Numbness in either arm or leg

Weakness in either arm or leg

'Weird' sensations in either arm or leg

Have you had any other treatment for your current problem?

Rate the severity of your symptoms from 1 - 10

1 2 3 4 5 6 7 8 9 10

(1 being very mild, and 10 being severe)

Medical History & General Health

Have you ever had spinal X-rays?

Yes No

Do you smoke?

Yes No

Do you exercise regularly?

Yes No

If yes, what type of exercise do you do and how regularly?

Have you ever had any form of surgery or been hospitalised?

Yes No

If yes, please provide details below

Have you ever sustained any broken bones?

Yes No

If yes, please provide details below

Have you ever been in a car accident?

Yes No

If yes, please provide details below

Are you currently taking any form of medication?

Yes No

If yes, please list all medications below

Do you have, or have you ever had, a serious health problem such as heart disease, diabetes, cancer?

Yes No

If yes, please provide details below

Have any of your family members suffered from any serious or hereditary diseases?

Yes No

If yes, please provide details below

Are you often troubled by headaches?

Yes No

If yes, please describe the severity and frequency below

Do you feel stressed?

Yes No

If yes, does it make your problem worse?

Yes No

Are you subject to blackouts, dizzy spells, or fainting?

Yes No

Do you suffer from fatigue?

Yes No

Do you suffer from night sweats or fever?

Yes No

Do your joints ever swell?

Yes No

If yes, are they worse at night?

Yes No

Have you lost appetite or weight in the past year?

Yes No

Are you troubled with digestive problems?

Yes No

Have you noticed any blood or mucus in your bowel movements?

Yes No

Do you suffer with shortness of breath or chest pain on exertion?

Yes No

Do you suffer from cramps or pain in either leg when walking?

Yes No

If yes, does it ease with rest?

Yes No

Do you have any pain or increased frequency on passing water?

Yes No

Do you have any lumps or unusual swellings anywhere on your body?

Yes No

Do you have any other information you feel is relevant to your health?

I agree to have my details saved

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