• Patient Registration Form

    Patient Registration Form

    DISCLAIMER: This form is hosted by JotForm.com - your information will be transmitted to the Health+ Diabetes Clinic via JotForm's secure servers, and a copy of your responses will be emailed to you automatically upon completion.

  • This survey may take up to 10 minutes to complete.

    The form is designed to run on a desktop or laptop computer. We cannot guarantee it will display correctly on tablets or mobile phones.

  • Who is completing this form?
  • Gender*

  • What are your pronouns?*

  • Have you been given a referral for treatment by your GP or another doctor?*

  • To proceed, you will first need to obtain a referral from your local doctor. Once you have a referral please either email a copy to mail@drcarey.com.au or call 07 3839 1777 to discuss alternative options.

  • If you have a copy of your referral on hand, please pause this form and email a copy to mail@drcarey.com.au now. If you are unable to email your referral, please call 07 3839 1777 to discuss alternative options.

  • Account details

  • Which of the following describes you?*

  • Medicare

  • Department of Veteran Affairs

  • Reason For Referral

  • MAIN REASON(S) FOR REFERRAL*

  • Have you had any blood tests in the past 12 months?

  • Medication and Allergies

  • Are you currently taking any regular medications?*
  • Are you currently taking any regular supplements?*
  • Do you have any allergies to medications?*
  • Do you have any other allergies? (eg foods, insect bites, grass, etc)*

  • Past Problems and Procedures

  • Have you been diagnosed with any of the following:*

  • Lifestyle Questions

  • Do you smoke?*
  • How often do you drink alcohol?*
  • And on the days you drink alcohol, how many Standard Drinks would you usually consume?

  • (A guide to the standard drink content of various beverages can be viewed at this site)

  • Do you ever consume 4 or more standard drinks in a single day?
  • What type of alcohol do you usually drink?

  • Diabetes

  • Do you have diabetes?*
  • Which type of diabetes?

  • When were you diagnosed with diabetes?

  • If you have a home glucose monitor, please keep a record of your blood sugar levels over a period of three days in the lead up to your appointment. Ideally, please record your pre-meal sugars and 2-hours after each meal. Our administration team will send out the required template for you to complete when your initial appointment is booked.

  • Do you inject insulin?
  • Do you have any of the following diabetic complications?

  • Please indicate if you currently receive REGULAR input from:
  • Do you hold, or do you intend to hold a commercial and/or Heavy Rigid driver's licence, (or get/renew certification as a rideshare driver)?

  • Weight Goals

  • Are you seeking assistance in managing your weight?*
  • Rows
  • Rows
  • Have you ever seen a professional dietitian before?
  •    

  • Hunger Patterns

  • What time(s) of day do you feel hungriest?
  • On an average day, which main meals would you eat?
  • On an average day, how many snacks would you eat (or drink) between meals?
  • What drives you to eat?
  • What foods do you crave the most?

  • Exercise

  • For the questions on this page, please consider only INTENTIONAL exercise sessions. Do not include incidental exercise such as walking while shopping. You may include walking if it is part of a deliberate effort to incorporate physical activity into your lifestyle (eg walking the dog).

  • How frequently do you do aerobic exercise?*
  • What do you typically do for aerobic exercise?

  • How long is each exercise session ?
  • How intense is each exercise session ?
  • Do you have easy access to a pool?*
  • Do you have exercise equipment at home?*
  • Do you use an activity tracker?

  • How frequently do you do resistance training? (Resistance training is a form of exercise that improves muscular strength and endurance)
  • What do you typically do for resistance training?

  • Are you satisfied with your current level of exercise?*

  • Based on your answers, this section does not apply to you. Please click "Next" to continue.

  • Other Health Concerns

  • Cardiovascular

  • Do you have, or are you being treated for, any of the following cardiovascular problems?*
  • Do you have fluid retention or lymphoedema?*
  • Is your lymphoedema managed with any of the following?

  • Sleep Details

  • Do you suffer from tiredness or fatigue?
  • Do you have trouble with any of the following?
  • If you wake in the night, getting back to sleep or staying asleep is hard due to:

  • How many hours of uninterrupted sleep would you usually get?
  • Do you use anything to help get to sleep?

  • Do you do any of the following while sleeping?
  • Do you wake up with any of these symptoms

  • Have you ever had an overnight sleep study?
  • Have you been diagnosed with sleep apnoea?
  • Was a CPAP machine prescribed?
  • How often do you use the CPAP machine?
  • Sleep Response to CPAP

  • Mood Details 

  • Please indicate if you experience any of the following mood disturbances*
  • Do you receive assistance with your mental health from any of the following?

  • Do you consent to us contacting your psychiatrist to obtain more information about your physical and mental health?*

  • Pain and Joint Details 

  • Do you have any of the following pain and joint problems?
  • In which area?
  • Have you been diagnosed with any of the following?
  • Do you take medication for pain or arthritis?

  • Does pain interfere with...?

  • Endocrine Details 

  • Do you have concerns with any of the following endocrine areas?*
  • What thyroid problems do you have?

  • What pituitary problems do you have?

  • What adrenal problems do you have?*

  • What osteoporosis concerns do you have?*

  • Do you have any of these female endocrine concerns?

  • Have you had these gynaecological procedures?

  • Male problems with?

  • Preferred appointment times

    Whilst we cannot guarantee availability of any specific days or times for your appointment, it is helpful to know if you have any restrictions to your availability due to family or work commitments. Please indicate your preferred days and rough times for appointments. Select as many as apply:
  • Rows
  • Which of the following (if any) apply to your availability to attend appointments?

  • We will endeavour to provide the most accessible appointment times when you have parenting or work pressures that may affect your availability, however there is always a high demand for appointments with Dr Carey. We therefore cannot guarantee we will always be able to provide appointments according to your preferences. 

  • Cancellation Policy

  • At the Health+ Diabetes Clinic we wish to provide our patients with a premium specialist service. However, last minute cancellations can make this difficult to sustain.

    It is our practice policy that patients provide at least 7 days’ notice if an appointment with Dr Carey is moved or cancelled. If due notice is not given, or an appointment is not attended, then a late-notice fee of $70 will be charged.

    The fee will be waived in the following circumstances:

    1. Patient is ill or injured and obtains a medical certificate.
    2. An immediate family member is ill/injured and obtains a medical certificate.
    3. An immediate family member has passed away.

    Note that this policy also applies to members of the ADF and Department of Veterans Affairs.

     

     

  • I have read and agree to the cancellation policy as described above, and understand that I will be billed $70 for moving or cancelling an appointment with Dr Carey with less than 7 day's notice.*

  • Privacy Policy

  • Health+ Diabetes Clinic is committed to protecting the privacy of patient information and to handling your personal information in a responsible manner in accordance with the Australian Privacy Principles (APPs) and relevant state and territory privacy legislation.

    As a patient of the Health+ Diabetes Clinic you are required to consent to the collection of your personal information, and for its use in the following ways:

    • Administrative and billing purposes, including compliance with Medicare requirements.
    • Disclosure of information to other healthcare workers involved in your care.
    • Use of de-identified healthcare data for the purposes of quality assurance activities to improve clinic management.
    • To comply with legislative or regulatory requirements, such as notifiable disease reporting
    • To receive emails and SMS’s as a main form of communication regarding your healthcare and management.

     

    Patients who wish to look at their information held by the clinic, or who have queries about the privacy of their information can discuss this with the practice manager or doctor. You can assist in maintaining the accuracy of your information by advising the clinic of any changes to details.

    You can view our Privacy Policy on our website www.drcarey.com.au or request a copy from reception.

  • Financial consent statement

    The following information is provided as a guide only - your individual needs and costs may vary.

  • The Health+ Diabetes Clinic is a private billing practice. Payment is expected at the time of the appointment. 

    Individual appointments and programs may vary and may affect the potential costs involved. Specific costs are detailed in an email sent to you once your initial appointments have been confirmed. Please contact reception for a current fee schedule.

    Medicare rebates are available for doctor’s appointments. Medicare rebates for Allied Health appointments are available for patients who have completed a Team Care Arrangement (TCA) through their GP. In lieu of a TCA, patients with private health extras cover may be able to claim partial rebates for dietitian appointments.

    The cost of medications, scans and pathology tests are billed by other providers independently. Most general investigations will be bulk billed with no out of pocket expense, but it is the responsibility of the patient to clarify if there are additional costs, which may vary depending on the service providers.  

    Australian Defence Force patients and Department of Veterans Affairs patients with relevant conditions will have their appointment expenses covered by these providers where appropriate. 

    For further clarification on appointments and costs please call and speak to our reception team 07 3839 1777.

  • Email Communication Statement

  • The Health+ Diabetes Clinic sends emails via Mailchimp to communicate important updates from the Clinic e.g. upcoming closures, medication issues, policy changes etc. We do also conduct surveys for quality assurance. We also on occassion send helpful tips from the Dietitians. This email is not for selling or advertising. If you would like to receive updates as stated above please provide your consent and we will add you to our mailing list. Any concerns please email manager@drcarey.com.au.

  • If you have concerns, please indicate that you have read the statement by clicking the check box, and then contact the clinic once you have submitted this form.    

  • You have reached the end of the questionnaire. Please click "Submit" to finish.

  • Please remember to email a scan or photograph of your referral to mail@drcarey.com.au if you have not already done so. Appointments cannot be booked until a referral is received. If you are unable to email your referral, please call 07 3839 1777 to discuss alternative options.

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