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Patient's Form

    How Did you find about us?

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    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.