New Patient Intake Form v1.0

New Patient Intake Form v2.0

Please complete this form before you appointment with one of our doctors.
Today's Date*

DayMonthYear
Date
Full Name*

First NameLast Name
Profile Picture*

Please upload a profile picture of yourself
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First Name
Last Name
Sex*
Date of Birth*

DayMonthYear
Date
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Patient's Mobile Number*
Medicare No.
Medicare Line No.
Medicare Card Exp Date
Regular GP Name
Regular GP Clinic Name
Emergency Contact*

First NameLast Name
Emergency Contact Number*
Please enter a valid phone number.
Do you have any DRUG or other allergies?*

History of past illnesses?
History of past operations / surgery?
Any dental work?
Please list all CURRENT Medications and Supplements (including DOSES and FREQUENCY)*
Any recent use of ANTIBIOTICS? If yes, which one?*
Previous and Recent Vaccinations and when?*
please list according to Month and Year
What do you have for breakfast and morning tea?*
Lunch and Afternoon Tea?*
Dinner and Late Supper?*
Any Food Intolerances?*
Do you fast?*
Appetite (good/bad)?*
Quality of sleep - Do you sleep well?
What time do you go to bed?
How long does it take you to fall asleep?
Do you wake up in the night? If so, how often & at what times?
Do you feel refreshed upon waking?
Do you take any sleep aids/drugs?
Computer/iPads/TV before bed?

Racial Heritage?
eg English, African, Pacific Islander etc
Any Genetic or Familial Illness?
Family history of cancers?
History of Chronic or Viral Infections:
Q-fever / Rickettsia / Typhus / Ross River Virus?
Hepatitis?
Viruses/CMV/EBV?
Covid? When was the last infection?
Any symptoms of Covid but tested negative in the last 6 months?
Social History
What work do you do?*
Is your work stressful?
Who do you live with?
Smoking history including current & previous?
Alcohol history including current & previous?
Is there anything in life that is causing you a lot of STRESS?
Family / Domestic/ Parents / Siblings / Children?*
Psychological, childhood traumas or assaults?*
Prolonged Bereavement?*
Any particularly STRESSFUL or TRAUMATIC life event within FIVE years of your diagnosis or that you feel significant as a trigger for your condition?*
Exposure to Environmental Toxins (Chemicals / Radiation / Amalgams / Mercury)?*
Do you Exercise? How often and what type?
Relaxation and Meditative Practice e.g. mindfulness, yoga, Tai Chi, meditation
Any Relaxation Meditative Practice e.g. mindfulness, yoga, Tai Chi, meditation?
What do you do to relax or for other joyful activities?
Please sign below to confirm that you acknowledge and accept the total Onboarding Fee which includes a pre-consult, first medical consult, and post-consult appointments. The fee is as discussed or advertised on the website. Also, by signing you are confirming that the above details are true and accurate. Please also note that Dr. Binjemain supports conventional cancer management or medical management and may also refer you to a suitable oncologist or specialist if you do not have one.

Please also note that we require 48 hours' notice for cancellation of appointments. Failure to do this will result in a charge of 100% of the consultation fee.
Full Name*
Signature*

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Date*

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Date
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New Patient Intake Form v2.0