Patient Intake Form - Salus | Dr Danielle Wadley

Name*

First Last

Date of Birth

DD

MM

YYYY

Email*

(IF PATIENT IS A CHILD PLEASE PROVIDE PARENTAL DETAILS)

Mobile Phone*

Home Phone

Address*

Street Address City ZIP / Postal Code

Next of kin details

Next of Kin Name

First Last

Mobile

Relationship

DO YOU CONSENT TO YOUR MEDICAL DETAILS TO BE DISCUSSED WITH YOUR NEXT OF KIN?

Yes
No

Patient Details

Medicare Number

Ref Number

Expiry Date

DD

MM

YYYY

Private Health Insurance Fund

Insurance Number

DVA card

White
Gold

DVA card expiry

DD

MM

YYYY

Aged Pension Number

Aged Pension expiry

Local Dr / GP

Worker's compensation details

Worker's compensation?

Yes
No

Employer Name

Insurance company

Claim Number

Case manager

Phone

Medical Information

What 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)

Is it getting worse/better/staying the same?

Is it worse after certain activities?

Do you have?

Swelling
Catching / Clicking / Locking
Burning or Numbness

Treatment:

Boot
Pain relief
Physiotherapy
Ankle brace
Podiatry
Alternative therapy: acupuncture, chiropractor
Other

Other: (please detail)

Type of ankle brace:

Do you have underlying medical problems?

Do you smoke?

Yes
No

If YES, how many?

Do you drink Alcohol?

Yes
No

If YES, how many?

Allergies:

Medications:

Occupation:

Sports or Leisure activities:

Living arrangements:

Alone
Family
Stairs
Steep Hill

Radiology

Standing Xrays
CT
MRI
Bone scan
Other

Location done:

South coast radiology
North coast radiology
Queensland XR
GCR
Qscan
IRIS
Radiant
Other

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:

Yes
No