Patient Information
Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Title {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
First Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Middle Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Surname {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Preferred Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Suburb {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Post Code {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Occupation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Sporting Activities & Frequency (Eg. Walking, gym classes twice a week, yoga each day) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Next of Kin | Emergency Contact Person
Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Relationship {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Offers & Events
Please tick the box if you would NOT like to be kept informed of upcoming offers and events {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Health Insurance Details
Enter 10 Digit Medicare Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Patient Line Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Expiry Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Private health Insurance Fund Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Membership Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Patient Line Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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}
Clinic Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Other Health Care Providers (Eg. Rheumatologist, Endocrinologist, Physiotherapist)
Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Profession {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Profession {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
How Did You Hear Abour Dr Kingsford?
If Applicable Please Provide The Name Of The Referrer {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Past Medical History
Allergic Rhinitis {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Fibromyaglia {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Manic Depression (Bipolar state) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Asthma {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Hallux Valgus (Bunion deformity) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Menopausal Symptoms (Flushing) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Cerebral Vascular Accident (Stroke) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Hepatitis A/B/C {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Morton's Neuroma {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Chronic Fatigue Syndrome {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Hypercholesterolaemia {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Myocardial Infarction (Heart Attack) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Clinical Depression {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Hypertension (High Blood Pressure) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Osteoarthritis {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Diabetes (Type 1) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Diabetes (Type 2) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Hypotension (Low Blood Pressure) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Plantar Fasciitis (Or heel spur pain) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Deep Vein Thrombosis (Blood clot) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Ingrowing Nails (Onychocryptosis) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Pneumonia (Or pleurisy) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Epilepsy {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Lesser Toe Deformities {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Rheumatoid Arthritis {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Other Condition {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Other Condition {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Other Condition {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Are You A Smoker? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
If yes how many per day? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Or year you gave up smoking {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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}
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}
Please list any previous surgical procedures or injuries (include year) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Other
Your Weight {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Your Height {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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}
Custom made foot orthoses {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Privacy & Consent
Signature {{ Cognito.resources["required-asterisk"] }} , { 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.
In signing this form you consent to the collection and dissemination of information as described. You understand that provision of your medical history is necessary to provide you with effective, safe and efficient treatment. You agree to notify Dr Kingsford’s rooms if you have any changes in your health.