Clinic Questionnaire

The initial intake form is important because many health problems can mimic disorders of the lower limbs. This establishes your health background, for things such as surgeries, accidents, the onset of your immediate condition, and other details affecting current health. Examining your history also helps the podiatrist determine whether the immediate reasons for your consult is, in fact, podiatric  in relation.

Please fill out all information to the best of your ability and note patients who have reservations about ticking any questions may discuss these with the podiatrist personally. 

All case histories are treated with absolute confidentiality.

Name *
Name
Address *
Address
If you do not have a regular GP - Who did you see last. If you don't have one - tick "I don't have one"
We need to know this as some health funds require specific item numbers
If under 18, full name of parent or legal guardian
If under 18, full name of parent or legal guardian
Do you have a Care Plan from your doctor?
Are you seeing us for a work cover/TAC claim?
We are grateful that our practice grows by referral
Major Complaint
include symptoms such as type/location/radiation/duration
include information such as history/causation
Do you play any sports/exercise regularly?
MEDICAL CORRESPONDENCE AND REFERRAL
Do you give consent for your clinical information to be communicated to your general practitioner or preferred health practitioner? *
Our practice specialises in treating problems of the spine and associated disorders of the nervous system. A proportion of our patients come via referral from their medical practitioner. As such, it is standard practice to correspond with your medical practitioner where appropriate.

Location

17 Wittenoom Street,
East Perth WA 6004

☎︎ 08 9221 8458

info@spinesportscentre.com.au