Tired - {{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

Let's explore your tiredness further.

How long have you been feeling tired?

Can you still perform your usual daily duties?

YesNoUncertain

How many hours of sleep do you have per night?

Do you wake up feeling refreshed?

YesNoUncertain

Do you snore at night (or has a partner mentioned that you snore)?

YesNoUncertain

Are you currently stressed or anxious about something in particular?

YesNoUncertain

Have you had any recent illnesses?

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.

List all your medications (Include Name, Dose and Frequency)

Please list any allergies.

Allergy

Severity

Please list any surgeries.

Surgery

Do you smoke?

YesNoI used to smoke

Do you use recreational drugs?

NoI have previously usedI currently use

Upload any additional information.

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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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