Patient Registration/Medical History

1
Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Day
Month
Year
3
Email* This field is required.
example@example.com
4
Phone Number* This field is required.
5
Address
Street Address
Street Address Line 2
City
Please Select
Please Select
QLD
NSW
VIC
SA
NT
WA
ACT
State
Post Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Medicare details* This field is required.
Card No.
Individual Ref No.
Expiry Date
7
Do you have a health fund?* This field is required.
YESNO
8
Health fund details* This field is required.
Fund Name
Fund Number
9
Emergency contact* This field is required.
Full Name
Contact No.
10
Sexual Orientation
Hetrosexual
Bisexual
Homosexual
11
Gender at Birth* This field is required.
Female
Male
12
Gender Identifcation* This field is required.
Female
Male
Non-Binary
Transgender
13
Preferred pronosuns* This field is required.
She/hers/her
He/him/his
They/them/theirs
14
Ethnicity* This field is required.
15
Do you live alone?* This field is required.
YESNO
16
Alcohol Consumption - Number of drinks per week on average* This field is required.
Non Drinker
1 to 2
3 to 4
Greater than 5
17
Smoker* This field is required.
Never
Ex-smoker
Yes - Nicotine
Yes - THC
Yes - Nicotine & THC
18
Weight & Height* This field is required.
Height in CM
Current Weight in KG’s
Heaviest Weight and Year
Lowest Weight and Year
19
Please enter the age of each of your first degree family members eg Mother, Father, Sister, Brother, Daughter, Son* This field is required.If your family member is deceased please put the age at which they passed away.
20
Auto-Immune DisordersPlease fill in for your family members e.g. parents, siblings, children, grandparents, aunties, uncles and grand children.
Yes
Family Members
Bowel cancer
Row 0, Column 0
Row 0, Column 1
Stomach cancer
Row 1, Column 0
Row 1, Column 1
Cancer other
Row 2, Column 0
Row 2, Column 1
Coeliac disease
Row 3, Column 0
Row 3, Column 1
Crohns
Row 4, Column 0
Row 4, Column 1
Ulcerative colitis
Row 5, Column 0
Row 5, Column 1
Other auotimmune disease
Row 6, Column 0
Row 6, Column 1
Fatty liver disease
Row 7, Column 0
Row 7, Column 1
Other liver disease
Row 8, Column 0
Row 8, Column 1
Bowel cancer
Stomach cancer
Cancer other
Coeliac disease
Crohns
Ulcerative colitis
Other auotimmune disease
Fatty liver disease
Other liver disease
Yes
Row 0, Column 0
Family Members
Row 0, Column 1
Yes
Row 1, Column 0
Family Members
Row 1, Column 1
Yes
Row 2, Column 0
Family Members
Row 2, Column 1
Yes
Row 3, Column 0
Family Members
Row 3, Column 1
Yes
Row 4, Column 0
Family Members
Row 4, Column 1
Yes
Row 5, Column 0
Family Members
Row 5, Column 1
Yes
Row 6, Column 0
Family Members
Row 6, Column 1
Yes
Row 7, Column 0
Family Members
Row 7, Column 1
Yes
Row 8, Column 0
Family Members
Row 8, Column 1
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21
Allergic DisordersPlease fill in for your family members e.g. parents, siblings, children, grandparents, aunties, uncles and grand children.
Yes
Family Members
Eosinophilic oesophagitis
Row 0, Column 0
Row 0, Column 1
Asthma
Row 1, Column 0
Row 1, Column 1
Excema
Row 2, Column 0
Row 2, Column 1
Hayfever
Row 3, Column 0
Row 3, Column 1
Anaphylaxis
Row 4, Column 0
Row 4, Column 1
Food allergies
Row 5, Column 0
Row 5, Column 1
Eosinophilic oesophagitis
Asthma
Excema
Hayfever
Anaphylaxis
Food allergies
Yes
Row 0, Column 0
Family Members
Row 0, Column 1
Yes
Row 1, Column 0
Family Members
Row 1, Column 1
Yes
Row 2, Column 0
Family Members
Row 2, Column 1
Yes
Row 3, Column 0
Family Members
Row 3, Column 1
Yes
Row 4, Column 0
Family Members
Row 4, Column 1
Yes
Row 5, Column 0
Family Members
Row 5, Column 1
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22
Reproductive DisordersPlease fill in for your family members e.g. parents, siblings, children, grandparents, aunties, uncles and grand children.
Yes
Family Members
Endometrisos
Row 0, Column 0
Row 0, Column 1
PCOS
Row 1, Column 0
Row 1, Column 1
Endometrisos
PCOS
Yes
Row 0, Column 0
Family Members
Row 0, Column 1
Yes
Row 1, Column 0
Family Members
Row 1, Column 1
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23
Psychiatric DisordersPlease fill in for your family members e.g. parents, siblings, children, grandparents, aunties, uncles and grand children.
Yes
Family Members
Anxiety
Row 0, Column 0
Row 0, Column 1
Depression
Row 1, Column 0
Row 1, Column 1
ADHD
Row 2, Column 0
Row 2, Column 1
ASD
Row 3, Column 0
Row 3, Column 1
PTSD
Row 4, Column 0
Row 4, Column 1
Anxiety
Depression
ADHD
ASD
PTSD
Yes
Row 0, Column 0
Family Members
Row 0, Column 1
Yes
Row 1, Column 0
Family Members
Row 1, Column 1
Yes
Row 2, Column 0
Family Members
Row 2, Column 1
Yes
Row 3, Column 0
Family Members
Row 3, Column 1
Yes
Row 4, Column 0
Family Members
Row 4, Column 1
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24
Mobility DisordersPlease fill in for your family members e.g. parents, siblings, children, grandparents, aunties, uncles and grand children.
Yes
Family Members
Hypermobility/hEDS
Row 0, Column 0
Row 0, Column 1
Recurrent dislocations
Row 1, Column 0
Row 1, Column 1
Hypermobility/hEDS
Recurrent dislocations
Yes
Row 0, Column 0
Family Members
Row 0, Column 1
Yes
Row 1, Column 0
Family Members
Row 1, Column 1
1 of 2
25
Lesser Know DisordersPlease fill in for your family members e.g. parents, siblings, children, grandparents, aunties, uncles and grand children.
Yes
Family Members
POTS
Row 0, Column 0
Row 0, Column 1
MCAS
Row 1, Column 0
Row 1, Column 1
Fibromyalgia
Row 2, Column 0
Row 2, Column 1
Chronic Fatigue Syndrome
Row 3, Column 0
Row 3, Column 1
POTS
MCAS
Fibromyalgia
Chronic Fatigue Syndrome
Yes
Row 0, Column 0
Family Members
Row 0, Column 1
Yes
Row 1, Column 0
Family Members
Row 1, Column 1
Yes
Row 2, Column 0
Family Members
Row 2, Column 1
Yes
Row 3, Column 0
Family Members
Row 3, Column 1
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26
Any other comments regarding family diseases
Huge
Large
Normal
Small
Ok
Ok
27
Please list all current medications and dose* This field is required.
28
Please list all current suppliments and brand
29
List Allergies or adverse drug reactions (list drug & reaction)
30
Medications tried in the past?
Improved
No effect
Side effect
Unknown
Famitodine
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Nizatidine
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Fludrocortisone
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
ivabradine
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Mododrine
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
CBD
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
LDN
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Ketitofen
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Famitodine
Nizatidine
Fludrocortisone
ivabradine
Mododrine
CBD
LDN
Ketitofen
Improved
Row 0, Column 0
No effect
Row 0, Column 1
Side effect
Row 0, Column 2
Unknown
Row 0, Column 3
Improved
Row 1, Column 0
No effect
Row 1, Column 1
Side effect
Row 1, Column 2
Unknown
Row 1, Column 3
Improved
Row 2, Column 0
No effect
Row 2, Column 1
Side effect
Row 2, Column 2
Unknown
Row 2, Column 3
Improved
Row 3, Column 0
No effect
Row 3, Column 1
Side effect
Row 3, Column 2
Unknown
Row 3, Column 3
Improved
Row 4, Column 0
No effect
Row 4, Column 1
Side effect
Row 4, Column 2
Unknown
Row 4, Column 3
Improved
Row 5, Column 0
No effect
Row 5, Column 1
Side effect
Row 5, Column 2
Unknown
Row 5, Column 3
Improved
Row 6, Column 0
No effect
Row 6, Column 1
Side effect
Row 6, Column 2
Unknown
Row 6, Column 3
Improved
Row 7, Column 0
No effect
Row 7, Column 1
Side effect
Row 7, Column 2
Unknown
Row 7, Column 3
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31
How were you delivered?* This field is required.
Vaginal delivery
Caesarean Section
Unknown
32
Were you breast fed?* This field is required.
Yes
No
Unknown
33
Antibiotic use throughout lifetime* This field is required.
< 5 courses
5-10 courses
10-15 courses
> 15 courses
34
Any Medical DiagnosisStart with the most recent diagnosis and work back.
35
Any Operations
36
Any significant infections ie EBV, influenza, COVID, pneumonia, etc, and COVID vaccination datesOne that your were hospitalised with, or caused your health to worsen after the infection.
37
Age of puberty/first period
38
Pregnancies - please include vaginal or C section and if tear, episotomy, Ventouse or deilvery forceps, miscarriages and years
39
Age of Menopause if applicable
40
Significant life stressors ie death, relationship breakdown, abuse, bullying, including years
41
Significant head/neck injury i.e. whiplash, concussion, including years
42
Have you had a colonoscopy or gastroscopy* This field is required.
Please Select
Please Select
No
Colonoscopy
Gastroscopy
Colonoscopy & Gastroscopy
43
What year was your last scope?
44
Colonoscopy/Gastroscopy year findings - Please have a copy of the reports and the biopsy results for your appointment as these are important * This field is required.
45
When did you last feel well?
46
Do you know what triggered your health decline?
47
What age or when did you first notice a problem with your gut?
48
How often are you using your bowels
e.g. everyday or ..... days per week
49
What motion do you regularly pass?
50
Current Diet
Gluten Free
Dairy Free
Low Carb
Vegetarian
Pescetarian
Carnivore
Vegan
Other
51
How much water do you drink each day?
Under 1L
1-2L
More than 2L
52
How much salt do you eat a day?
No added Salt
Add to food
Salt tablets
53
Amount of salt in grams if know
54
What is your predominamt bowel habit?
Constipation
Diarrhoea
Alternating constipation and diarrhoea
55
Do you ever pass blood or mucous?
YESNO
56
With your consitpation what is the longest time between bowel motions?
57
On a bad day how often do you go to the toilet?
58
Is your diarrhoea proceded by abdominal pain and urgency?
YESNO
59
Does the pain go away after opening your bowels?
YESNO
60
Do you have?
Haemorrhoids
Fissures
Pain during defecation
Lump prolapse during defecation
61
Do you experience?
Difficulty evacuating a hard motion
A feeling of incomplete emptying of your rectum after a motion
Decreased rectal sensation (i.e. dont get the urge or can feel faeces in your rectum but no desire to go)
Increased rectal sensation (i.e. always feeling as if you need to pass motion)
Do you ever need to apply perineal pressure to help evacuate a motion
Do you ever have episodes of faecal incontinence
62
Have you ever had to manually remove faeces?
YESNO
63
Gut Symptoms - Do you suffer from?
Reflux
Trouble swallowing - sensation of food sticking on the way down
Loss of appetite
Feeling full quickly
Nausea
Regular vomiting
Abdominal pain
Bloating
64
Do you have trouble swallowing
Solids
Liquids
65
Which meal is worse for making you feel full
Breakfast
Lunch
Dinner
66
Is your nausea
Occasionally
Often
Daily
67
Is your daily nausea
Present when you wake up and are still laying in bed
Worse when you stand up in the morning
Worse after food
68
What makes your nausea worse after food
Size of the meal
Solids/liquids
Type of food carb/meat/fat/other
Morning or evening
Don't Know
69
Have you ever vomited food eaten the day before?
YESNO
70
Circle the area you have pain
71
How often do you have abdominal pain?
Occasionally
Often
Daily
72
Is your abdominal pain
After eating
Immediately upon eating
Within 5 to 10 mins of eating
30 minutes of longer of eating
N/A
73
Does you abdominal pain worsen after
NSAIDS i.e. iburprofen
Alcohol
Stress
Other
74
Is your abdominal pain improved in any particular position?
75
Does your abdominal pain make you want to use your bowels?
YESNO
76
Does using your bowels relieve your abdominal pain?
YESNO
77
Do you suffer from wind pain?
YESNO
78
Where is your bloating?
Upper stomah
Lower stomach
All over
79
When bloated do you distend i.e. look pregnant
YESNO
80
Is the bloating painful?
YESNO
81
Is your bloating
After eating
Progressively throughout the day
Both
N/A
82
Do you have trouble with
Unexplained weight gain
Unexplained weight loss
83
In the last 6-12 months how much weight have you lost/gained?
84
Have you noticed that any of the following worsen your symptoms* This field is required.
Stress
Infection
Hormones
Types of food
After eating
Position
Other
85
Other Symptoms - tick all that apply.
Headaches
Brain Fog
Difficulty Concentrating
Light Headed
Awareness of heart beating
Fast heart rate at rest
Short of Breath
Excessive sighing
need to take a big breath to get enough air in
Sweating too much
No sweating
Always Cold
Always Hot
Intolerant to hot/cold
Fatigue
Lack of labidio
Decreased vaginal lubrication
Dry mouth
Dry eyes
Difficulty emptying bladder
Always needing to urinate
Frequent urine infections
Easy Bruising
Funny Rashes
Do you get 'Hangry'
If you feel unwell, does eating sugar make you feel better
Night Sweats
Nightmares
None of the above
86
Tick all that apply on a regular basis to bother you.* This field is required.
Reflux
Trouble swallowing
Vomiting
Loss of appetite
Feeling full quickly
Unexplained weight loss
Uexplained weight gain
Trouble losing weight
Nausea
Bloating
Abdominal Distension
Abdominal pain
consitipation
Diarrhoea
Alternating constipation/diarrhoea
87
Describe your abdominal pain* This field is required.Location, worse after eating, size of meal or particular type of food. Worse before using bowels, after using bowels, no relation. What position helps relieve the pain, i.e. standing, laying. which side etc.
Huge
Large
Normal
Small
Ok
Ok
88
Abdominal Distension - location and timing
Please Select
Worse in the morning
After eating
End of the day
Anytime
Upper abdomen
Select all that apply
89
Bloating - location and timing
Please Select
Please Select
Worse in the morning
After eating
End of the day
Anytime
Upper abdomen
90
Nausea - timing* This field is required.
Please Select
Please Select
Worse in the morning
After eating
End of the day
Anytime
91
Do you tend towards constipation, diarrhoea or alternate* This field is required.
Please Select
Please Select
Constipation
Diarrhoea
Alternate
92
Does using your bowels make any of your symptoms better or worse?* This field is required.
93
What Bristol stool do you pass (can be multiple numbers)* This field is required.
94
When going to the toilet do you* This field is required.Select what applies to you
95
Do you use any of the following regularly?
96
What is your top concern or question?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
97
On a scale of 1 - 10, how willing are you to change your diet/lifestyle?
98
On a scale of 1 - 10, how supported are you to change your diet/lifestyle?
99
Your other Medical Providers
Dr. Name
Clinic Name & Suburb
Clinic Phone #
Consent for cc'd correspondence
GP
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Psychologist
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Neurologist
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Cardiologist
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Physio
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Dietician
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Other
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Other
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
GP
Psychologist
Neurologist
Cardiologist
Physio
Dietician
Other
Other
Dr. Name
Row 0, Column 0
Clinic Name & Suburb
Row 0, Column 1
Clinic Phone #
Row 0, Column 2
Consent for cc'd correspondence
Row 0, Column 3
Dr. Name
Row 1, Column 0
Clinic Name & Suburb
Row 1, Column 1
Clinic Phone #
Row 1, Column 2
Consent for cc'd correspondence
Row 1, Column 3
Dr. Name
Row 2, Column 0
Clinic Name & Suburb
Row 2, Column 1
Clinic Phone #
Row 2, Column 2
Consent for cc'd correspondence
Row 2, Column 3
Dr. Name
Row 3, Column 0
Clinic Name & Suburb
Row 3, Column 1
Clinic Phone #
Row 3, Column 2
Consent for cc'd correspondence
Row 3, Column 3
Dr. Name
Row 4, Column 0
Clinic Name & Suburb
Row 4, Column 1
Clinic Phone #
Row 4, Column 2
Consent for cc'd correspondence
Row 4, Column 3
Dr. Name
Row 5, Column 0
Clinic Name & Suburb
Row 5, Column 1
Clinic Phone #
Row 5, Column 2
Consent for cc'd correspondence
Row 5, Column 3
Dr. Name
Row 6, Column 0
Clinic Name & Suburb
Row 6, Column 1
Clinic Phone #
Row 6, Column 2
Consent for cc'd correspondence
Row 6, Column 3
Dr. Name
Row 7, Column 0
Clinic Name & Suburb
Row 7, Column 1
Clinic Phone #
Row 7, Column 2
Consent for cc'd correspondence
Row 7, Column 3
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100
Off Label Prescribing Consent* This field is required.Click on the highlighted "Off Label Prescribing"
101
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