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Patient's Form

How Did you find about us?

GoogleAdWordsGoogle MapFacebookFriend/RelativeGPPodiatristOthers (Pls Specify)

Patient Details

 
Mainly sitStandWalk

Next of kin/contact person in an emergency

Medicare Details Not Applicable

Private Health Insurance Not Applicable

HospitalExtra

Veteran Affairs Card No

General Practitioner (please list your usual G.P. or the doctor you would attend if medically required)

Other health care providers (e.g. rheumatologist, endocrinologist, physiotherapist, chiropractor, osteopath)

Past Medical HistoryI have no medical conditions

( Please select any of the medical conditions below that apply to you. For each medical condition please enter the medication dose and frequency you take for it)

Allergic Rhinitis (hay fever) Yes Hypotension (low blood pressure)Yes
Do you smoke? Please list how muchYes
AsthmaYes Infectious DiseasesYes
Cerebral vascular accident (stroke)Yes In growing nails (Onychocryptosis)Yes
Chronic Fatigue SyndromeYes Lesser toe deformitiesYes
Clinical DepressionYes Manic depression (bipolar state)Yes
CellulitisYes Menopausal symptoms (flushing)Yes
Diabetes (Indicate type I, II)Yes Morton’s neuroma painYes
Deep vein thrombosis (blood clot)Yes MRSAYes
EpilepsyYes Myocardial infarction (heart attack)Yes
FibromyalgiaYes OsteoarthritisYes
Hallux valgus (bunion deformity)Yes Plantar fasciitis (heel spur pain)Yes
Hepatitis (indicate type A, B, C) Yes Pneumonia (or pleurisy) Yes
HypercholesterolaemiaYes Rheumatoid arthritisYes
Hypertension (high blood pressure)Yes Ulcer/Wound BreakdownYes
Other ConditionsYes

  We respect 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 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 the podiatrist and/or the podiatric surgeon of any change in my health.

  Dr Robert Hermann is a podiatric surgeon and not a medical practitioner – therefore his fees are NOT COVERED BY MEDICARE. I confirm that I am aware of these facts.