Abdominal Discomfort - {{first name}} {{surname}}

General Information

First Name

Surname

Date of Birth

Email Address

Home Phone

Mobile Phone

Home Address

Medicare Card Number - IRN *

How did you find out about us?

Emergency Contact Information

Emergency contact

Phone

Emergency contact’s relationship to you

Work Information

Current work status

EmployedRetiredNot workingLight Duty

Occupation

Abdominal Discomfort onset

Sudden onset

Gradual onset

Long term

Any associated symptoms?

Abdominal pain

Nausea/vomiting

Diarrhoea

Constipation

Weight loss

Weight gain

Loss of appetite

Fatigue

Blood in stools

Mucus in stools

Relief after passing wind

Dietary and lifestyle factors

Dairy products trigger the symptoms

High fibre foods trigger the symptoms

Carbonated drinks trigger the symptoms

No identifiable trigger

Family History of Bowel Conditions?

Do bowel conditions exist in the family?

YesNoUncertain

Medical Background

Please list all your medical conditions (e.g. High Blood Pressure, Asthma, Diabetes etc.)

Please list any medications you are currently taking.

Medications (Include Name, Dose and Frequency)

Please list any allergies.

Allergy

Please list any surgeries.

Surgery

Do you smoke?

YesNoI used to smoke

Do you use recreational drugs?

NoI have previously usedI currently use

Consent

I confirm that above information I have provided is true, complete and accurate. I agree to be contacted by a health professional via telehealth. *

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