Patient Information

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Next of Kin | Emergency Contact Person

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Health Insurance Details

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

General Practitioner (Please list your usual GP or the doctor you would attend if medically required)

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Other Health Care Providers (Eg. Rheumatologist, Endocrinologist, Physiotherapist)

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

How Did You Hear Abour Dr Kingsford?

Choice {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Past Medical History

Please insert the year you were diagnosed with, or first experienced symtoms of, any if the following conditions

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
YesNo NoYes
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Medication

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Other

{ binding firstError.message }
{ binding firstError.message }

If you wear foot orthoses / arch supports,what years were these fitted?

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Privacy & Consent

{ binding firstError.message }

 

Dr Kingsford respects your privacy. All information collected, is stored securely and accessed only by our staff. In order to provide the highest standard of podiatric care, there are times when we may communicate with your other healthcare providers.

I have read the privacy information and consent to collection and dissemination of information as described. I understand provision of my medical history is necessary to
provide me with effective, safe and efficient podiatric management. I have answered all questions to the best of my knowledge. I agree to notify Dr Kingsfords rooms of any change in my health.

{ binding firstError.message }

Patient Information

Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Title {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
First Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Middle Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Surname {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Preferred Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Suburb {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Post Code {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Occupation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Sporting Activities & Frequency (Eg. Walking, gym classes twice a week, yoga each day) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

Next of Kin | Emergency Contact Person

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Relationship {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Health Insurance Details

Enter 10 Digit Medicare Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Patient Line Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Expiry Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Private health Insurance Fund Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Membership Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Patient Line Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

General Practitioner (Please list your usual GP or the doctor you would attend if medically required)

Doctor's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Clinic Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Other Health Care Providers (Eg. Rheumatologist, Endocrinologist, Physiotherapist)

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Profession {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Profession {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

How Did You Hear Abour Dr Kingsford?

Choice {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
If Applicable Please Provide The Name Of The Referrer {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Past Medical History

Allergic Rhinitis {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Fibromyaglia {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Manic Depression (Bipolar state) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Asthma {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Hallux Valgus (Bunion deformity) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Menopausal Symptoms (Flushing) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Cerebral Vascular Accident (Stroke) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Hepatitis A/B/C {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Morton's Neuroma {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Chronic Fatigue Syndrome {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Hypercholesterolaemia {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Myocardial Infarction (Heart Attack) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Clinical Depression {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Hypertension (High Blood Pressure) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Osteoarthritis {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Diabetes (Type 1) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Diabetes (Type 2) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Hypotension (Low Blood Pressure) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Plantar Fasciitis (Or heel spur pain) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Deep Vein Thrombosis (Blood clot) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Ingrowing Nails (Onychocryptosis) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Pneumonia (Or pleurisy) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Epilepsy {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Lesser Toe Deformities {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Rheumatoid Arthritis {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Other Condition {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Other Condition {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Other Condition {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Are You A Smoker? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
If yes how many per day? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Or year you gave up smoking {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Medication

Please list any forms of medication you take including amount and frequency of dosage (Eg Aspirin, 300mg, 1 tablet each morning) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Please list any allergies, sensitivities or dietary restrictions (Eg. Band aid blistering, penicillin skin rash, no gluten etc...) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Please list any previous surgical procedures or injuries (include year)  {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Other

Your Weight {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Your Height {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

If you wear foot orthoses / arch supports,what years were these fitted?

Preform (off the shelf) insoles {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Custom made foot orthoses {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Privacy & Consent

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

 

Dr Kingsford respects your privacy. All information collected, is stored securely and accessed only by our staff. In order to provide the highest standard of podiatric care, there are times when we may communicate with your other healthcare providers.

I have read the privacy information and consent to collection and dissemination of information as described. I understand provision of my medical history is necessary to
provide me with effective, safe and efficient podiatric management. I have answered all questions to the best of my knowledge. I agree to notify Dr Kingsfords rooms of any change in my health.

{ binding firstError.message }