LHM NEW CLIENT HEALTH RECORD

Having up-to-date medical information enables us to provide the best care possible.

Please complete this online form at least one week before your appointment.

If you do not have access to a computer/ internet or smartphone- please have a family member support you.

If you experience any technical difficulties, please contact us 02 4911 2336.

We appreciate this is a very comprehensive form that does take a lot of time and effort for you to complete, so grab a cuppa and know that your information adds incredible value to your consultation with our Specialist team~ thank you!

Title

First Name *

Middle Name *

Last Name *

Please upload a photo - head shot like passport, for patient identification, safety and accreditation purposes. *

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If you are completing this form via your phone, iPad, or PC, simply upload a photo you have stored on your device.

Street Address

Postal Address

Marital status *

Date of Birth *

Birth Gender

Gender Identity

Home Telephone

Mobile Telephone *

Consent to receive SMS? *

YesNo

Email Address *

Please advise your type of phone you have, for video consultation purposes *

AppleGalaxyOther

Only complete this section if you require a Specialist RMS assessment for your drivers license.

Please indicate below

Australian - Non IndigenousAboriginalTorres Strait IslanderBoth Aboriginal and Torres Strait Islander

Other?

My Health Record is a safe and secure place to keep your key health information, available to you and your healthcare providers anytime, including in an emergency. To learn more please click on this link: Digitalhealth.gov.au

For example, My Health Record enables Dr. Diez Alvarez to review past pathology, imaging, GP summaries, and discharge summaries that have been uploaded to your My Health Record, this helps him gain more insight into your health and the best treatment and care management for you.

Do you consent to Lower Hunter Medical accessing your "My Health Record"? *

YesNo

Do you consent to Lower Hunter Medical uploading your consultation report to My Health Record? *

YesNo

If you have a My Health Record access code, please enter it here:

Medicare Number (if applicable) *

Medicare Line Number *

Medicare Expiry Date *

DVA Card

Injury covered

DVA Number

DVA Expiry Date

Private Health Fund

Private Health Fund Card Number

Commonwealth Benefit

Number

Expiry Date

Do you receive NDIS?

YesNo

Have you been assessed by ACAT?

YesNo

Emergency Contact Name *

Emergency Contact Telephone *

Emergency Contact Relationship *

Next of Kin Name *

Next of Kin Telephone *

Next of Kin Relationship *

Do you have children? *

YesNo

If yes, do they live close to you? *

Do you consent to a partner/ friend or family member to attend consultations, access information and results and/or speak to medical and administrative staff on your behalf. If yes, you need to identify person or persons in the next question. *

YesNo

Please list partner/ friend or family member whom you give consent to attend consutations, access information and results, and/or speak to LHM medical and administrative staff on your behalf. Please provide their contact number. *

General Practitioner's Name, Address and Telephone *

Funding Provider

Workers Compensation Details - if applicable

Usual pharmacy's name, telephone and fax details.

Medications *

Please provide details of other health professionals involved in your care. Include name, speciality and contact details.

Do you consent to sharing investigation results with these practitioners? Your privacy is important to us, so you will need to specifically consent for us to share your results. *

YesNo

Please provided details of allied health or natural therapists involved in your care. Include name, modality and contact details. *All diabetic patients please list your Podiatrist and Optometrist/ Ophthalmologist and last date of visit.

Supplements - Please list any current herbal or nutritional supplements being taken. Please list dosage and reason for taking these. *

Allergies /Intolerances: *

What is the main reason for your visit today? *

Please provide any diagnosis and symptoms that trouble you.

Do you have hearing difficulties?

Yes NoSometimes (eg loud places)

Do you wear hearing aids

Do you wear glasses

Do you have other health concerns?

YesNo

How would you rate your general health?

ExcellentGoodFairPoor

Are you pregnant?

YesNo

What is your weight? (KG) *

What is your height? (CM) *

What is your abdominal girth (waist) measurement?

What is your usual blood pressure and heart rate (pulse)? *

Reminder: if you have any technical difficulties, the form is saved and we can send it back to you, contact us via admin@lowerhuntermedical.com.au or call 02 4911 2336.

Medical History

Have you been in hospital in the last 12 months?

YesNo

Have you had previous surgery?

YesNo

Hospitilisation

YesNo

Pregnancies

YesNo

Motor Accident

YesNo

Falls *

YesNo

Physical Injuries

YesNo

Mental Health Illness

YesNo

Is your mother alive? *

YesNo

Is your father alive? *

YesNo

If your parents are alive, how old are they? Do they have any medical conditions? If not, what was their medical history. *

Do you have any siblings (brother/sisters)? *

YesNo

Please list any medical conditions your siblings have.

Reminder: if you have any technical difficulties, the form is saved and we can send it back to you, contact us via admin@lowerhuntermedical.com.au or call 02 4911 2336.

Diet and Lifestyle

How would you rate your diet?

GoodFairPoor

Do you eat fresh fruit and vegetables daily?

YesNoSometimes

How many meals do you have a day *

Do you drink alcohol? *

YesNo

Do you drink soft drink or fruit juice?

YesNo

Do you drink water?

YesNo

Do you exercise regularly? *

YesNo

Do you use recreational drugs?

YesNoOccasionallySocially

How would you describe your weight?

IdealPoorImproving

Smoking *

Never smokedQuitCurrent smoker

If a current smoker, how many smokes daily and how long for. Additonally, if you have given up smoking, how long ago did you cease smoking and please state how much you smoked prior to giving up. If you have never smoked please N/A. *

How many hours per night do you normally sleep?

Do you have trouble getting to sleep or staying asleep ?

YesNo

If you have sleeping difficulties please describe:

Please rate your stress level on a scale of 1 (very low) to 10 (extremely high). *

Please rate your level of pain from 0 (no pain) to 10 (severe pain). *

What medications do you use to relieve your pain?

What is your COVID 19 Vaccination status? *

Have you had both your COVID 19 Vaccines?Have you had your booster(s)?Have not had any COVID 19 vaccinations to date.

Reminder: if you have any technical difficulties, the form is saved and we can send it back to you, contact us via admin@lowerhuntermedical.com.au or call 02 4911 2336.

Musculo-skeletal History - please indicate if you have had any of the following:

Osteoarthritis

YesNo

Osteoporosis

YesNo

Fractures/ Dislocations/ Disc injuries

YesNo

Do you require any mobility aids?

YesNo

X-rays/CT/MRI/Ultrasounds

YesNo

Area of the body

SpineHeadLimbsAbdominal

Where do you usually have your scans/ x-rays done?

System Review - please indicate if you have had any of the following:

Psychological and Mental Health *

DepressionAnxietyOtherNil

If you have Sleep Apnoea for example do you use CPAP?

Dietary Issues

Anorexia NervosaBulimia NervosaObesityBinge Eating Disorder

Infective

Do you have any current infection?

YesNo

Dermatology

Do you have any skin conditions?

YesNo

Is your skin broken now? (wounds or infections) *

YesNo

Where do you usually have your pathology (blood tests) done? *

What was the date of your last blood test?

Workplace

What is/was your occupation? *

Do you still work? *

YesNo

Consent

I declare that information to be true and correct to the best of my knowledge. I understand that providing incorrect information can be dangerous to my (or the patient's) health. I undertake to inform the doctor(s) of any changes in medical status. I also consent to the sharing of my (or the patient's) clinical information when necessary for treatment or care by other professionals, or as required by law.

I give my consent for Lower Hunter Medical to access any of my medical information, reports, results from investigations and examinations, from any source for the purpose of my assessment and management.

I confirm that I am responsible for the payment of treatment fees including cancellation fees if they are incurred. (Please note that 24 hours notice is required for appointment cancellations or cancellation fees may be charged)

Signature *

Draw signature|Type signatureClear

Date *

As Dr. Diez Alvarez is an Internal Medicine Specialist, he reviews all body systems in the context of your symptoms and medications, the more information you provide the better he is able to support you. Please use the following to upload any reports for other specialists (such as Cardiologist/ Neurologist etc..), images (X-Rays/ CT/ MRI), results (pathology, studies (such as sleep study, lung function tests etc..) or any other health documentation. Thank you.

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Please list any comments or concerns here:

Once you press submit, you will receive an instant confirmation of successful submission and you will also receive an email confirmation.

If the form does not instantly state "successfully submitted", please scroll up and any questions not completed will be highlighted in red, these will need to be completed before submission is successful.

If you have any technical difficulties, the form is usually autosaved at various intervals and we can access it for you. If the form is no longer accessible to you, we can resend you the link to your work submitted so far.

Please do not hesitate to call us at any time on 02 49 112 336

Thank you :-)

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