2019 Medical History v5 (published)

Medical History and Contact Details

New patients should complete this form one week prior to their first appointment
This survey may take up to 20 minutes to complete. If your browser has cookies enabled, you are able to close this page at any time and return later. Your responses will be saved on your computer for up to 48 hours.

The form is designed to run on a desktop or laptop computer. We cannot guarantee it will work on tablets or mobile phones.
Full Name*

PrefixFirst NameLast Name
Birth Date*

MonthDayYear
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

SuburbState

Postcode
Best Contact Number*
Alternative Phone Number
E-mail address
Have you been given a referral for treatment by your GP or another doctor?*

Yes, and I would like to upload it nowYes, and the referral has already been sentI do not have a referral yet
Upload Referral file*

Upload a File

Cancelof
Unfortunately, to proceed any further in the booking process you will first need to obtain a referral from your local doctor. Once you have a referral please either upload here, or fax, email or post a copy to us.

GP Details
Referring Doctor's Name
Is this your usual GP?
Usual GP's Name
Usual GP's Practice
Account details
Employment Status

No current employmentPart-TimeFull-TimeRetired
Primary occupation
Driving Licence?
Which of the following BEST describes you?

I have a Medicare cardMy medical treatments are covered by the Department of Veteran AffairsI am not eligible for Medicare or Veteran's Affairs benefitsOther
Medicare
Medicare Number
Department of Veteran Affairs
DVA Number
DVA card type

Medication and Allergies
Are you currently taking any regular medications?*

YesNo
List of Current Medications (click 'Add to form' after each entry, including if there is only one entry)
Do you have any allergies to medication?*

YesNoNot Sure
Allergies to Medication (click 'Add to form' after each entry, including if there is only one entry)

Past Problems and Procedures
List any major medical problems that other doctors have diagnosed (click 'Add to form' after each entry to save it. even if there is only one entry)
List any Past Operations or hospital procedures (click 'Add to form' after each entry, even if there is only one entry)

Case Conferencing
The Health+ Diabetes Clinic programs rely on a team approach to healthcare. Dr Carey works closely with allied health professionals at the clinic, including dietitians, exercise physiologists, pharmacists, psychologists, nurses, podiatrists, optometrists and/or pharmacists. In order to get the best results, the Health+ team meet weekly to share information about our patients.

These Case Conferences help to ensure that your care team are all on the same page and working towards the same goals. The patient does not need to be present, and the service is bulk billed. Up to five Case Conferences may be conducted for each patient in any calendar year. Medicare will be charged on each occasion and an outcome summary generated for you.

Patients are able to opt-out of this service if they have any concerns about information sharing. Should you have specific information that you do not wish for our team to discuss, please notify the relevant health professional at your appointment.
Do you consent to the Health+ team discussing your health needs, goals and progress during Case Conferences?*

I am willing for Case Conferences to be conducted on my behalfI do not wish for Case Conferences to be conducted for me, or there is particular medical information that I would like to be withheld
Based on your answers, this section does not apply to you. Please click "Next" to continue.

Cancellation Policy
At the Health+ Diabetes Clinic we wish to provide our patients with a premium specialist service. However, last minute cancellations can make this difficult to sustain.

It is our practice policy that patients provide at least 7 days’ notice if an appointment with Dr Carey is moved or cancelled. If due notice is not given, or an appointment is not attended, then a late-notice fee of $70 will be charged.

The fee will be waived in the following circumstances:

1.     Patient is ill or injured and obtains a medical certificate.

2.     An immediate family member is ill/injured and obtains a medical certificate.

3.     An immediate family member has passed away.

Note that this policy also applies to members of the ADF and Department of Veterans Affairs.
I have read and agree to the cancellation policy as described above, and understand that I will be billed $70 for moving or cancelling an appointment with Dr Carey with less than 7 day's notice.*

I agreeI do not agree
We understand that some patients are unable to commit to a 7-day notice period due to their work or other commitments. We are able to offer a more flexible arrangement for these patients via an alternative fee schedule which is 10% higher than standard fees. If you choose this arrangement we ask, as a courtesy, for you provide 24-hours notice to move or cancel appointments.
Please select an option:*

I wish to be placed on the flexible fee schedule and understand that this is billed 10% higher on fees for appointments with Dr CareyI do not consent to the 7 day cancellation policy and do not wish to be placed on the flexible fee shedule
You have indicated that you do not consent to our clinic's standard cancellation policies. A member of our team will need to discuss a mutually suitable arrangement with you at the time of booking your first appointment.
Privacy Policy
Health+ Diabetes Clinic is committed to protecting the privacy of patient information and to handling your personal information in a responsible manner in accordance with the Australian Privacy Principles (APP’s) and relevant state and territory privacy legislation.

As a patient of the Health+ Diabetes Clinic you are required to consent to the collection of your personal information, and for its use in the following ways:

- Administrative and billing purposes, including compliance with Medicare requirements.

- Disclosure of information to other healthcare workers involved in your care.

- Use of de-identified healthcare data for the purposes of quality assurance activities to improve clinic management.

- To comply with legislative or regulatory requirements, such as notifiable disease reporting

- To receive emails and SMS’s as a main form of communication regarding your healthcare and management.

Patients who wish to look at their information held by the clinic, or who have queries about the privacy of their information can discuss this with the practice manager or doctor. You can assist in maintaining the accuracy of your information by advising the clinic of any changes to details.

You can view our Privacy Policy on our website www.drcarey.com.au or request a copy from reception.
I have read and understood this summary, and consent to the collection, storage, and (where applicable) disclosure of my personal and medical information for the purposes listed.*

I agree

You have reached the end of the questionnaire. Please click "Submit" to finish.
Should be Empty:

	Year tried	kg lost	Kept weight off for ___ months?
Weight watchers
Jenny Craig
Tony ferguson
Atkins Diet
Paleo Diet
Low GI Diet
Low Fat Diet
Optifast
Dietitian
Gym/trainer
Duromine
Other

Medical History and Contact Details

GP Details

Account details

Reason For Referal

Lifestyle

Medication and Allergies

Past Problems and Procedures

Current Problems

Diet History

Exercise History

Case Conferencing

Cancellation Policy

Privacy Policy