WOMEN’S HEALTH NEW CLIENT INTAKE FORM

Title

Name

First Name

Last Name

Date of Birth

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

Occupation

Usual GP / Practice Address

How did you find out about us?

Private Health Fund (If applicable)

Who is your Private Health Fund provider?

Area Requiring Treatment

What part of your body needs treatment? When did your injury, pain or dysfunction start?

Past Medical History

Have you been diagnosed with any medical conditions?

Medications

Do you take any medications? If so, please list

Have you had any previous surgery?

Current Exercise / Physical Activity

Are you currently participating in any exercise or activity?

Have you been referred by a GP or specialist?

Is this a Medicare referral?

Medicare referrals are eligible for rebates through Medicare, however a gap payment will still be charged at the time of your appointment.

Are you currently pregnant? If so how many weeks?

Do you experience pain associated with your pelvic floor?

Have you been diagnosed with vaginismus or vulvodynia and require treatment for this?

Yes

Have you been diagnosed with endometriosis and are seeking treatment for this?

Yes

Are you requiring a pessary to be fitted as a part of your treatment?

If unsure what this is select no

Yes

Have you had any scans or x-rays recently?

Declaration

BY SUBMITTING THIS FORM; - You declare that the information supplied is correct to the best of your knowledge - That all debts owed in relation to the provision of services are your responsibility - You give us permission to use your information to communicate with relevant stakeholders (doctors/case managers etc) and for occasional marketing purposes

I Agree