Alpha Edge Clinic - New Patient Form

PATIENT DETAILS

MrMrsMissMs

First Name

Last Name

Preferred Name

Date of Birth

Gender

MaleFemale

Ethnicity

ATSI

AboriginalTorres Strait IslanderNone of the Above

PATIENT CONTACT DETAILS

Mobile Phone *

Work Phone

Email *

Address *

Postcode

City / Suburb

State

Delivery Address - This will be your delivery address for your prescriptions *

I confirm that my delivery address is correct. *

I also agree to take full responsibility if my delivery is not accepted or picked up from the post office within the cold shipping time frame. *

MEDICARE

Medicare First Name *

Medicare Surname *

Medicare Card No. *

Expiry *

Medicare Number *

Do you use a different name in your medicare card? *

YesNo

Hobbies and Sport

Hobbies & Sport *

Past Surgery

Please list ALL surgeries you have had and the year they occured *

Past Medical History

Please list ALL medical problems you have had and the year they began - Please * any work-related injuries and note if it is a workers comp claim *

All Medication/Nutrients

Please list all script medications, vitamins, minerals, herbals etc. Dosage and time taken I.E Morning - Night *

Allergies

Please list ALL allergies to medications, vitamins, minerals, herbs, food, etc. *

Family History

Please indicate whether there is a history of the following conditions in your family: heart disease, high blood pressure or circulatory conditions, cancer, diabetes, osteoarthritis, ankylosing spondylitis, rheumatoid arthritis, multiple sclerosis, muscular dystrophy, mental illness, auto-immune disorders, asthma, allergies, psoriasis, eczema, alcoholism, drug abuse or any other conditions that are pertinent to your present state of health. *

Smoking & Alcohol

Do you drink Alcohol - How much do you drink per week on average? *

Do you Smoke? *

Weight Loss

In the past 12 months, have you had any weight loss or weight gain please answer accordingly *

Physical Health

What time of day is it lowest? *

What time of day is it highest? *

How often do you exercise per week? *

Daily Every other dayOnce or Twice per weekNever

What exercises are part of your typical routine? *

Mental Health

Food intake

What do you typically eat throughout the day?

Breakfast? *

Lunch? *

Dinner? *

Please check the appropriate boxes

Treatment

What is the main condition for coming to us and what are the symptoms or problems, and what is your major goal, you want us to help you with? *

List the very first time you noticed the condition and describe carefully anything that you suspect may have played a role in the development. *

SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

I hereby authorize the medical team and staff to perform examinations and/or treatment deemed necessary. *

I understand that proceeding with the Doctor consultation and scripting will require two non-refundable payments: one at the time of consultation, which is part of the processing cost, and another for the scripting. *

I declare that I am over 18 years of age and I am NOT under any sporting or professional code where the treatments or medicines offered are prohibited. *

FULL NAME *

Today's Date *

Patient *

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