Dr Peterson & Dr Allen Patient Questionare

Dr Peterson & Dr Allen

Complete health assessment and information form

Patient Details

Title *

Please select a title

Surname *

Surname is required

Given Names *

Given names are required

Preferred Name

Date of Birth *

Please enter a valid date (DD/MM/YYYY)

Age *

Age must be between 1 and 100

Residential Address *

Residential address is required

Post Code *

Post code must be 4 digits

Mailing Address (if different)

Mobile Phone *

Mobile phone is required

Home Phone

Work Phone

Email *

Please enter a valid email address

Occupation

Insurance & Card Details

Medicare Number *

Medicare number must be 10 digits

Reference Number *

Reference number must be between 1 and 10

Expiry Date *

Please enter a valid date (DD/MM/YYYY)

Pension/Health Care Card

Expiry Date

Please enter a valid date (DD/MM/YYYY)

Veteran’s Affairs Gold Card

Expiry Date

Please enter a valid date (DD/MM/YYYY)

Private Health Cover

Yes

Name of Fund

Emergency Contacts

Next of Kin Name *

Next of kin name is required

Relationship *

Relationship is required

Phone *

Phone number is required

Emergency Contact (if different)

Phone

Cultural & Other Information

Do you identify as Aboriginal and/or Torres Strait Islander?

Yes

Both

Please select at least one option.

Other Cultural Group

Do you have any allergies?

Yes

Please select at least one option.

If yes, please list

How did you hear about this service?

Medical History

Current Health Issues

Current health issues are required

Previous Medical History

Previous Surgical History

Allergies and Sensitivities

Current Medications/Supplements

Vaccinations

Note: Please bring in a copy of your health history information for the past 6 months.

Social and Lifestyle History

Alcohol Consumption *

Non-drinker

Monthly or less

2-4 per month

2-4 per week

4+ per week

Please select at least one option.

Smoking Status *

Never

Ceased

Current smoker

Year ceased (if applicable)

Amount per day/week

Please select at least one option.

Vigorous Activity (running, swimming, aerobics, tennis, bike riding) *

1 day

2 days

3 days

4+ days

Never

Please select at least one option.

Other Activities (meditation, yoga, gardening, swimming, dancing) *

Yes

Please select at least one option.

Occupation

Pets

Overseas holidays (within the last 12 months)

Pregnancy History

Not applicable

Times Pregnant

Miscarriages

Premature births < 36 weeks

Induced abortions

Year	Outcome (birth/miscarriage/induced abortion)

Family History

Please include history of heart problems, thyroid issues, diabetes, cancers, high blood pressure, depression and anxiety, bone and joint problems, menstrual, pregnancy problems, other

Mother

Father

Sister/s

Brother/s

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Maternal or Paternal Aunts

Maternal or Paternal Uncles

Maternal or Paternal Children

General Past History

General Past History (tick if yes)

Thyroid problems

Stress

Significant weight gain/loss

Nickel allergy

Diabetes/gestational diabetes/pre-diabetes

Skin rashes/dermatitis

Other/details

Gynaecological History

Menstrual History

Heavy periods

Spotting in cycle or brown bleeding

Pelvic pain

Pre-menstrual syndrome (PMS)

Age at first period

Period length (bleeding days)

Average Cycle length (total between periods)

Longest Ever Cycle

Shortest ever cycle

Family History

Family History (tick if yes)

Diabetes

Miscarriages

Endometriosis

Infertility

Thyroid problems

Other

For Women Only

Date of last cervical screen

Number of children

Painful periods

Yes

Number of pregnancies

Post-natal depression

Yes

Heavy periods

Yes

Number of miscarriages

Age when first used pill

PMT

Yes

Last mammogram

History of Fertility Tests, Procedures and Treatments

Not applicable

Test	Y/N	Details
Day 21 progesterone
Semen Analysis
AMH
Ultrasound Pelvis/Follicles
Other

Fertility Procedures

Not applicable

Procedure	Y/N	Details
HSG (Hysterosalpingogram or tube studies)
Hysteroscopy
Laparoscopy
Other

Fertility Medical Treatments

Not applicable

Medical Treatments	Y/N	Dates (approx.)/Details
Contraceptive pills
Mirena
Implanon
Clomid or Serophene
Injectable Hormone Treatment
ART Treatments
IVF
ICSI
GIFT
ZIFT
Artificial Insemination – Intrauterine (IUI)
Husband (AIH)
Donor (AID)
Other

Fertility Surgical Treatments

Not applicable

Treatment	Y/N	Details
Cervix Surgery
Uterine Surgery
Ovarian Surgery
Tubal Surgery
Other

Relationship History

Relationship/Marital Status

Married

De facto

Single

If partner - Length of time

PMS Screening Questionnaire

PMS is often a marker of hormonal abnormality so it is very relevant to your assessment. Please indicate symptoms you experience at least 4 days before your menstrual period that are relieved within the first couple of days of your period and have been present in at least 3 out of the past 6 cycles.

Severity Scale: 0 = none, 1 = mild (doesn't interfere), 2 = moderate (interferes but not disabling), 3 = severe (disabling)

Symptom

Severity (0-3)

# Days

I feel depressed or hopeless

I have headaches

I feel tearful or cry easily

I feel "on edge, irritable, anxious or wired"

I have decreased interest in my usual activities

I have difficulty concentrating

I feel easily fatigued; lack energy

I have food cravings (salt, foods high in sugar or chocolate)

I have trouble sleeping or sleep more than usual

I feel overwhelmed or out of control

I have breast tenderness

I have a sensation of bloating or temporary weight gain

DASS-21 Assessment

Instructions: Please read each statement and select a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

Rating Scale:

0 - Did not apply to me at all
1 - Applied to me to some degree, or some of the time
2 - Applied to me to a considerable degree, or a good part of time
3 - Applied to me very much, or most of the time

1. I found it hard to wind down

Please select at least one option.

2. I was aware of dryness of my mouth

Please select at least one option.

3. I couldn't seem to experience any positive feeling at all

Please select at least one option.

4. I experienced breathing difficulty (eg, excessively rapid breathing, breathlessness in the absence of physical exertion)

Please select at least one option.

5. I found it difficult to work up the initiative to do things

Please select at least one option.

6. I tended to over-react to situations

Please select at least one option.

7. I experienced trembling (eg, in the hands)

Please select at least one option.

8. I felt that I was using a lot of nervous energy

Please select at least one option.

9. I was worried about situations in which I might panic and make a fool of myself

Please select at least one option.

10. I felt that I had nothing to look forward to

Please select at least one option.

11. I found myself getting agitated

Please select at least one option.

12. I found it difficult to relax

Please select at least one option.

13. I felt down-hearted and blue

Please select at least one option.

14. I was intolerant of anything that kept me from getting on with what I was doing

Please select at least one option.

15. I felt I was close to panic

Please select at least one option.

16. I was unable to become enthusiastic about anything

Please select at least one option.

17. I felt I wasn't worth much as a person

Please select at least one option.

18. I felt that I was rather touchy

Please select at least one option.

19. I was aware of the action of my heart in the absence of physical exertion (eg, sense of heart rate increase, heart missing a beat)

Please select at least one option.

20. I felt scared without any good reason

Please select at least one option.

21. I felt that life was meaningless

Please select at least one option.

Privacy Authorisations

By submitting this form, you consent to the collection and processing of your personal information in accordance with our privacy policy.