Another Symptom - {{first name}} {{surname}}
General Information
First Name
Surname
Date of Birth
Email Address
Medicare Card Number - IRN
*
Home Phone
Mobile Phone
Home Address
How did you find out about us?
Emergency Contact Information
Emergency contact
Phone
Emergency contact’s relationship to you
Work Information
Current work status
Employed
Retired
Not working
Light Duty
Occupation
Health Information
What symptom do you have?
Tell us about your symptom in dot point form.
List all your medications (include Name, Dose and Frequency).
Please list all your medical conditions (e.g. High Blood Pressure, Asthma, Diabetes etc.).
Please list any allergies.
Please list any surgeries.
Do you consume alcohol?
Never
Daily
Once a week
Once a month
Once a year
Do you smoke?
Yes
No
I used to smoke
Do you use recreational drugs?
No
I have previously used
I currently use
Consent
I confirm that the 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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