Confidential Medical Information

Please make sure you've also completed the New Patient Form
https://mooroolbarkspecialistcentre.snapforms.com.au/form/new-patient-form
(link opens in a new window)

Your Full Name *

Your Date of Birth *

Please include as much information as you can. This information will help the doctor to focus on your current issues, rather than spending time asking questions about your history and current medications. You can attach documents at the end of the form. All information is stored securely in line with Australian Privacy Legislation. If you would prefer to complete a paper form and bring it to your appointment please contact the clinic on 9725-3003 and we will email it to you.

Medical History

If you selected other, please specify the reason

If you selected other, please specify the medical problem below (or use this text box to expand on anything ticked above)

List of previous surgeries or serious injuries (including all fractures/broken bones) and approximate dates

Please provide information of your family medical history. List family member (eg. Maternal Grandmother) and all known medical conditions (even if not obviously related to your current issue)

Smoking and Alcohol

If yes, how many cigarettes do you smoke a day?

If you selected vape, what type and how often?

If you used to smoke or vape please provide further information. How long did you smoke/vape? How often? When did you quit?

If you drink alcohol please explain how many standard drinks you typically drink in a day or week (eg. 1-2/night for 5 nights and 6-8/night for 2 nights a week)

Medication Details

List of current medications (include name, strength and how often you take it) - please don't say 'see referral' as it often doesn't match what people actually take every day

List your known drug allergies (name of drug and reaction if known)

Diabetes

Year of Diabetes diagnosis

How old were you when you were diagnosed with Diabetes?

Diabetes treatments previously or currently (select all that apply)

Year you commenced tablets for Diabetes

Year you commenced insulin (if relevant)

Year you first started injections other than Insulin for Diabetes

Are you using Continuous Blood Glucose Monitoring? *

Yes, all/most of the timeYes, intermittentlyNo

Are you registered for Continuous Blood Glucose Monitor funding through the NDSS (usually only for Type 1 Diabetes)?

Yes, funded by NDSSNo, funded by DVANo, I pay a subscription & get regular deliveriesNo, I buy them intermittently

Date current insulin pump was started (approximate ok)

Have you ever had a Diabetic Ketoacidosis?

NoYes

If you answered yes to Diabetic Ketoacidosis, when was your most recent episode?

Have you ever had an episode of Severe Hypoglycaemia (a low sugar that resulted in you being unable to treat it yourself. Can include being unconscious or needing an ambulance)?

Yes, many timesYes, but only onceNo

If you answered yes to Severe Hypoglycaemia, when was the most recent episode?

Usual Diabetes Educator

Date of last Diabetes Educator appointment

Usual Dietitian

Date of last Dietitian appointment

Usual Optometrist

Date of last Optometrist appointment

Usual Ophthalmologist

Date of last Ophthalmology appointment

Usual Podiatrist

Date of last Podiatry appointment

Usual Dentist

Date of last Dentist appointment

Osteoporosis

Thank you for answering these questions on the form to the best of your ability - it really will help your Doctor and allow more time to discuss treatment options.

Is your referral for Osteoporosis?

YesNo

If you've been referred for Osteoporosis Management what is the main issue?

To discuss (potentially) starting treatment for the first timeTo discuss a different treatment option to the current treatment due to a side effectTo discuss a different treatment option to the current treatment due to having a fracture on treatmentTo discuss a different treatment option to the current treatment for other reasonsOther reason

Have you had a fracture/broken bones? *

YesNo

When & where was your last DEXA (Bone Density Test)?

Please provide details of previous DEXA's - date & location (please send through results if not already in the referral)

Please list your previous fractures/broken bones - location (eg. right wrist), date (approximate ok) and how it happened (eg. fall down stairs, trip over dog)

What treatment(s) have you had for Osteoporosis previously & currently? (select all that apply)

Date of last Prolia

If you've previously had Aclasta / Zoledronic Acid please list dates of previous infusions (exact date of any infusions in the last 12 months especially appreciated)

What is your Gender? (different questions will be asked depending on your Gender) *

FemaleMale

What age were you when you had your first period? *

How many pregnancies have you had?

How many months/years did you breastfeed (in total)?

What age did you go through Menopause (age at the time of your last Period)?

Have you had Hormone Replacement Therapy? If so, what and for how long?

Is there a Family History of Osteoporosis? (select all that apply) *

Have either of your parents had a fractured/broken hip? Provide details if you can

Do you have Coeliac Disease? *

Yes, diagnosed within the last yearYes, diagnosed more than a year agoNo and have definitely been tested for itNo and unsure if tested for it

Do you have a Family History of Coeliac Disease? (select all that apply) *

Yes, parent(s)Yes, sibling(s)Yes, Aunts/Uncles/CousinsNo

Do you have good Dairy/Calcium intake as a child/teenager? *

YesNoI don't know

Do you have Calcium in your diet now? Excluding calcium supplements. *

Yes, lots of dietary CalciumYes, some dietary Calcium (not sure if enough)No

What supplements are you currently taking for Osteoporosis (select all that apply) *

CalciumVitamin DOtherNone

Have you ever had low Vitamin D? *

YesNoI don't know

Do you have an Overactive Thyroid?

Yes, I have Graves' Disease currentlyYes, I have had Graves' Disease previously but not currently activeYes, I have Toxic Multinodular Thyroid DiseaseYes, my Thyroid is overactive but I don't know whyNo, my Thyroid is normal No, my Thyroid is Underactive (Hypothyroidism/Hashimotos)I don't know

Do you have Hyperparathyroidism or High Calcium? (currently or previously)

Yes, I have Hyperparathyroidism - high Parathyroid Hormone + high Calcium levelYes, I have Hyperparathyroidism - high Parathyroid Hormone, but normal Calcium levelNo, but I have had Hyperparathyroidism in the pastNo, I have a normal Parathyroid Hormone level & a normal Calcium levelI don't know

Have you ever had hormone blocking medications for treatment of Cancer?

Yes, hormone blockers for Breast/Ovarian CancerYes, hormone blockers for Testicular/Prostate CancerNo

When was your last Dental appointment?

Do you have any Dental Work planned? eg Fillings? Extractions? Root Canals?

Thank You

Thank you for completing this form. This information will be provided to your treating Doctor.

Please attach any relevant paperwork that has not already been provided to the clinic such as recent blood tests, letters from previous Doctor appointments, discharge summaries from a hospital admission. If you are unable to upload these documents then please bring them with you to your appointment.

Attach any relevant paperwork:

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I confirm that above information I have provided is true, complete and accurate. *

Date *

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