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Telephone No
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ACCOUNT DETAILS Responsibility for Account
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PATIENT HISTORY
To assist Dr Morgan, could you please complete the following questions?
This information is necessary to ensure quality care and treatment.
Do you or have you ever suffered with (PLEASE TICK)
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Heart problems
Heart surgery
Circulation problems
History of bleeding
Blood pressure
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Breathing difficulties
Headaches or migraines
Epilepsy, fits or seizures
Thyroid problems
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Heartburn/reflux/indigestion/ulcers
Bladder or kidney problems
Bowel problems
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Liver problems / Hepatitis (A, B or C)
HIV / AIDS
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Stroke
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Diabetes
Type 1
Type 2
Unsure
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Managed by
Insulin
Diet
Tablets
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Cancer
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MEDICATIONS (prescribed / over the counter/ health supplements)
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Have you taken recently
Blood thinning medication
Warfarin
Arthritis medication
Steroids or cortisone
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ALLERGIES (Please list any allergies to medications, food, rubber, etc)
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Have you ever been hospitalised?
Yes
No
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PLEASE SPECIFY
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Payment is preferred on the day of consultation. However, ACCOUNTS that are outstanding OVER 7 DAYS, an accounting fee of 30% of total account outstanding will be incurred, unless a prior arrangement has been made in writing.
I understand and agree to these account procedures.
I DO / consent to the disclosure of information to allied health personnel (GP, Physiotherapist, etc) for the primary purpose
of ongoing health care and treatment. ALL DETAILS PROVIDED ARE PROTECTED BY THE PRIVACY ACT AND OUR PRIVACY POLICY IS DISPLAYED FOR YOUR INFORMATION. *
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