EverPeak Patient Medical Questionnaire
Please complete this form to provide your medical history and current health information.
Full Name
*
First Name
Last Name
How did you hear about EverPeak
Please Select
Referral
Website
Social Media
Preferred Business Partners
Google
Email or Newsletter
Returning Client
Other
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Prefer not to say
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email Address
*
example@example.com
Medicare Number:
*
Medicare Reference Number:
*
Medicare Exp: (04/2030)
*
Presenting Concerns/Motivations/What brings you here today?
*
Overall Health (personal rating)
Excellent
Good
Fair
Poor
Do you currently have or have had:
High blood pressure
Heart disease
Chest Pain/tightness
High cholesterol
Fainting/blackouts
Asthma
COPD
Shortness of breath
Recent chest infections
Diabetes - Type 1 / Type 2
Thyroid disorder
Adrenal conditions
Pre-screen/Musculoskeletal
Neck pain
Back pain
Joint injury
Fractures
Osteoarthritis / Rheumatoid arthritis
Other
Neurological
Stroke
Seizures
Neuropathy
Migraines
Mental Health
Anxiety
Depression
PTSD
Other diagnosed condition
Other diagnosed condition (if applicable)
Gastrointestinal
Coeliac disease
Crohn's
IBS
Reflux
Genitourinary
Kidney disease
Bladder issues
Prostate issues
Skin Conditions
Eczema
Psoriases
Ulcers / wounds
Other Known Conditions
Cancer (current or past)
Autoimmune disease
Blood disorders
Immunocompromised status
If "yes" to any: Please provide additional details (diagnosis, onset, treatment, current status).
Do you have any allergies?
No known allergies
Medications
Food
Environmental
Other
Lifestyle factors - Alcohol
None
Occasional
Moderate
High
Lifestyle factors - Physical Activity
None
1-2 Days / Week
3-4 Days / Week
5+ Days / Week
Type(s) of exercise
Lifestyle factors - Sleep Quality
Good
Fair
Poor
Average Hours
Functional Capacity & Daily living - Do you experience difficulty with:
Walking
Standing
Sitting
Lifting
Stairs
Driving
Self-care
Work duties
Describe limitations:
Occupation & Typical Duties (please list these here)
Medications / prescribed or over-the-counter (please provide details)
Supplements / Herbal Products (please provide details)
Surgical & Hospital History (please provide details)
For Women / AFAB Clients
Pregnant
Breastfeeding
Post-partum
Menopause / perimenopause
For Men / AMAB Clients
Testicular concerns
Prostate concerns
Hormonal issues
Falls Risk:
History of falls
Unsteady on feet
Red Flags
Sudden unexplained weight loss
Night Pain
Fever or Chills
Loss of bowel or bladder control
Unexplained weakness
Severe or unrelenting pain
If yes to any, outline details:
Patient Goals - What are your primary goals?
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Final Declaration:
*
I declare the information provided is true and complete to the best of my knowledge.
I understand it is my responsibility to notify my clinician of any changes to my health or medications.
Consent & Privacy Acknowledgement
• I understand the purpose of collecting my personal and health information is to support safe, effective and appropriate clinical care. • I understand that my information may be shared with treating health professionals or third parties only with my consent or as permitted by law. • I acknowledge the clinic complies with AHPRA Codes of Conduct and Australian Privacy Principles.
Signature
*
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