Patient Intake Form Name* First Last Date of Birth MM DD YYYY Email* (IF PATIENT IS A CHILD PLEASE PROVIDE PARENTAL DETAILS)Mobile Phone*Home PhoneAddress* Street Address City ZIP / Postal Code Medicare NumberRef NumberPrivate Health Insurance FundInsurance NumberDVA cardWhiteGoldDVA card expiryAged Pension NumberAged Pension expiryWorker's compensation?YesNoEmployer's detailsInsurance companyClaim NumberContact NameContact NumberGeneral PractitionerName of PracticeNext of KinRelationshipContactDO YOU CONSENT TO YOUR MEDICAL DETAILS TO BE DISCUSSED WITH YOUR NEXT OF KIN?YesNoMedical InformationWhat is your main concern you'd like help with?Which side is affected? Right Left Both Please describe where the pain is:How bad is your pain?(0 = none, 10 = worst)12345678910When did the pain start?Is it getting worse/better/staying the same?Is it worse after certain activities?Do you have?SwellingCatching / Clicking / LockingBurning or NumbnessHave you had an injury / fracture / surgery?Please provide details.Height:Weight:Do you have underlying medical problems? Heart Disease Respiratory Disease Bleeding or Clotting disorders Stroke Diabetes Kidney Disease Liver Disease Other Please describe condition:Do you smoke?YesNoIf YES, how many?Do you drink Alcohol?YesNoIf YES, how many?Allergies:Medications:Occupation:Sports or Leisure activities:Upload your referral:PLEASE BE AWARE THAT PAYMENT FOR YOUR CONSULTATION IS TO BE MADE ON THE DAY. YOUR AGREEMENT IS REQUIRED FOR COMPLIANCE WITH THE PRIVACY LAWS TO THE FOLLOWING: I AGREE TO ALLOW DR WADLEY AND HER STAFF ACCESS TO MY MEDICAL RECORDS AND ALL RELEVANT INFORMATION REGARDING MY MEDICAL CONDITIONS AS REQUIRED TO ACHIEVE THE HIGHEST LEVEL OF CARE. THIS MAY INCLUDE FORWARDING INFORMATION TO OTHER HEALTH PROFESSIONALS.I agree:YesNo