Patient Intake Form - Salus | Dr Danielle Wadley

Name*

First Last

Date of Birth

MM

DD

YYYY

Email*

(IF PATIENT IS A CHILD PLEASE PROVIDE PARENTAL DETAILS)

Mobile Phone*

Home Phone

Address*

Street Address City ZIP / Postal Code

Medicare Number

Ref Number

Private Health Insurance Fund

Insurance Number

DVA card

White
Gold

DVA card expiry

Aged Pension Number

Aged Pension expiry

Worker's compensation?

Yes
No

Employer's details

Insurance company

Claim Number

Contact Name

Contact Number

General Practitioner

Name of Practice

Next of Kin

Relationship

Contact

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

Yes
No

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)

When did the pain start?

Is it getting worse/better/staying the same?

Is it worse after certain activities?

Do you have?

Swelling
Catching / Clicking / Locking
Burning or Numbness

Have 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?

Yes
No

If YES, how many?

Do you drink Alcohol?

Yes
No

If 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:

Yes
No