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New Patient Questionnaire
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Personal Details
First Name
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Last Name
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Date of Birth
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Day
Month
Year
Medicare Number
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Medicare Reference Number
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The number next to your name on your Medicare card.
Medicare Valid To
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Pensioner Concession Card, Concession Card, Commonwealth Seniors Health Card
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Yes
No
Card Number
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Card Valid To
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Day
Month
Year
Residential Address
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Street Address
City
State
Post Code
Do You Have A Home Phone?
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Yes
No
Home Phone Number inc. Area Code
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Example: 02 1234 5678
Mobile Number
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Email Address
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Ethnicity
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Occupation (Present and Past)
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Emergency Contact Name
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Emergency Contact Phone Number
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You or Your child's Health Journey
Responses relevant to the carer if it’s a child.
Are you ready for change?
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
The doctor may not be able to help this patient.
I value my health highly
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
The doctor may not be able to help this patient.
Addressing my health issues is now a priority in my life
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
The doctor may not be able to help this patient.
I am now willing to work hard to achieve my health goals.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
The doctor may not be able to help this patient.
I am responsible for achieving my health goals.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
The doctor may not be able to help this patient.
What are your complaints?
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What are your health goals? What will you feel when you have achieved your goal? Please List 3.
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What have you done so far to solve this problem(s)?
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Current symptom checklist
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Indigestion
Constipation
Excessive burping
Diarrhoea
Nausea or Vomiting
Loose stools but not watery
Abdominal Cramps or Pain
Regular Bowel Movement
Abdominal Bloating or Wind
Irregular Bowel Movement
Green or yellow coloured stools
Black coloured stools
Blood in stools
Weight gain
Weight loss
Intolerance to cold
Intolerance to heat
Anxiety
Depression
Dizziness or feeling light headed
Tiredness
Palpitations
Hair Loss
Hot flushes
Night sweats
For females: Heavy periods
Acne
For Females: Premenstrual Tension e.g. Emotional, Breast tenderness before menstruation
Poor Concentration or "Brain Fog"
Headaches
Migraines
Muscle cramps
White spots on nails
Cold hands and feet
Generalised aches and pains in muscles and joints
Frequent viral infections
Shortness of Breath
Chest pain
Breast lumps
Lumps in armpit, groin or neck
Blood loss from stomach or bowels
Chronic headaches
None Of The Above
Did you enjoy school?
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Yes
No
Typical grades in school:
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A
B
C
D
F
Tendency for Anger:
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High
Average
Low
Tendency for Anxiety:
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High
Average
Low
Pain threshold:
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High
Average
Low
Do you function well under stress?
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Yes
No
Are you competitive at sports?
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Very
Average
No
Family members or a carer can help fill out this section if required.
*
Please select the symptoms or traits that apply to you*
Poor Stress Control
Poor Short-Term Memory
Sensitivity To Bright Lights
Sensitivity To Loud Noises
Morning Nausea
Affinityf For Spicy And Salty Foods
Tendency To Delay Or Skip Breakfast
Tendency To Be Overweight
Very Dry Skin
Obsessive/Compulsive Tendencies
Pale Skin, Inability To Tan
Extreme Mood Swings
High Irritability And Temper
History Of A Reading Disorder
History Of Underachievement
Severe Inner Tension
Little Or No Dream Recall
Frequent Infections
Autoimmune Disorders
Premature Graying Of Hair
Abnormal Or Absent Menstrual Periods
Ringing In The Ears
Poor Muscle Development
History Of Perfectionism
“Fruity” Breath And/Or Body Odour
Stretch Marks (Striae) On Skin
Spleen-area Pain
Severe Depression
Severe Anxiety
Fear Of Airplane Travel, Tornadoes, Etc.
Very Strong Willed
Obsessions With Negative Thoughts
Joint Pains
Delayed Puberty
Poor Wound Healing
Dark Or Mauve-Colored Urine
Psoriasis
Tendency To Stay Up Very Late
Delusional Thoughts
Auditory Hallucinations
Social Isolation
Enjoys Spicy Foods
Dry Eyes And Mouth
Artistic Or Musical Ability
None Of The Above
Any other symptoms? If none say none.
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Past Medical History
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High Blood Pressure
Heart Disease
High Cholesterol
Asthma
Sleep Apnoea
Anxiety/Depression (please complete the next page )
Chronic Fatigue Syndrome
Fibromyalgia
Irritable Bowel Syndrome
Inflammatory Bowel Disease
Diabetes
Fatty Liver
Hypothyroidism
Hyperthyroidism
Rheumatoid Arthritis
Cancer
Endometriosis
Polycystic Ovaries
Uterine Fibroids
None Of The Above
Other list below. If none say none.
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Have you had surgery in the past? If yes, please list
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Do you have any family history of any condition? If yes, please list the conditions.
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Do you have any relevant results to show the doctor? E.g. blood test results, specialist reports, or scans.
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Yes
No
Please upload your files.
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Drop files here or
Select files
Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 10 MB.
Medication History
Please list any types of medication and dose you are currently taking. E.g. name of drug , strength of drug and how many times a day. If none say none.
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Please list any drug or food allergies. If none say none.
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Social History
Do you smoke? If so how many per day?
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Do you drink alcohol? If so how many per week?
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Who is at home with you?
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How often do you exercise in a week? And for how long?
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How many hours do you sleep each night?
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Do you use screens before sleep? e.g. watch tv, laptops, phones
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Do you sleep before midnight?
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Do you wake up in the middle of the night? e.g. 2am or 3am
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Do you wake up feeling refreshed?
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Any other current stressors? If none say none.
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Past Stressful Events
Please list any stressful or major life events you've experienced below together with when they happened and the impact they had upon your health. e.g. Work stress in my 20's and gained weight.
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Your Eating Habits
What did you eat for breakfast yesterday? *
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What did you eat for lunch yesterday?
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What did you eat for dinner yesterday?
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What do you drink in the day and how much ? e.g. 2 litres of water, 3-4 cups of coffee
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Do you snack between meals or after dinner? please list the items
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Do you eat when you feel stressed, emotional or bored?
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How often do you cook your own meals?
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How often do you eat ready made meals? e.g. takeaways, restaurants
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Terms and Conditions
Please carefully read, tick and sign at the end if you accept our terms & conditions.
Consent
*
I understand
integrative medical assessments, investigations and treatments may consist of a combination of pharmaceutical, lifestyle and complementary assessments and treatments. As a medical doctor, priority will be given to your acute and emerging medical needs at every appointment. All medical advice is provided within the scope of the extensive training in both mainstream and integrative medicine.
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Consent
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I understand
that some assessments and treatments may be considered to be outside the parameters of conventional medicine (considered “complementary, unconventional and/or emerging”) as defined by non-integrative medical doctors. You understand that some doctors may see these treatments as complementary, unconventional or emerging and may lack placebo-controlled double-blind studies of their scientific proof such that their use currently remains controversial. Some tests or treatments recommended will not be covered by Medicare and/or Private Health Insurance.
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Consent
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I understand
that medical information is provided as advice and you retain the right to choose or decline any recommendations provided. Where appropriate, you may be offered a choice between conventional or complementary medicine or undertaking no treatment. At all times it remains your right to consent or decline assessments and/or treatments. You are entitled and invited to seek further information as to this advice including what evidence exists for the use of any prescribed assessment or treatment, safety and risk factors involved in an assessment or treatment, possible outcomes and costs likely to be incurred with any treatment.
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Consent
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I understand
that these integrative medical assessments and treatments are supported by empirical knowledge, used widely by successful integrative medical doctors in Australia/overseas and are only prescribed with the utmost of care. You further understand that in undertaking any form of conventional and/or complementary integrative medical assessment or treatment that results cannot be guaranteed, and you accept this prospect.
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Consent
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I understand
that any supplement recommended is selected based on quality, optimal medical formulation, high safety profile and cost effectiveness. All supplements are Therapeutic Goods Administration approved within Australia. On occasion you may be prescribed a medication “off label” (outside of TGA guidelines), the use and potential risks of which will be discussed with you.
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Consent
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I understand
that supplements purchased off recommended websites like vital.ly, bioceuticals and metagenics are supplied for your convenience and a financial benefit from sale may occur. You are under no obligation to purchase supplements from these websites.
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Consent
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I understand
the tests, treatments and products are considered generally safe when used according to appropriate prescription and ongoing consultation with your prescribing doctor. Any specific risks associated with treatment will be discussed with you at the time of prescription.
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Consent
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I understand
that this written consent forms part of an ongoing relationship with additional implied and verbal consent undertaken during each subsequent appointment unless I choose otherwise. I have been invited to openly and freely discuss any aspect of my medical care that I am concerned with on an ongoing basis.
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Consent
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I understand
that my Rights and Responsibility in attending Dr Mehmet for medical advice and consent to my ongoing assessment and treatment of my own free will, understanding that I may choose to discuss my care and/or decline my consent at any time.
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Consent
*
I understand
that the consult will not fully be covered by Medicare and I will pay the full fee and get a rebate from Medicare if eligible. Health fund rebates may not apply.
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Consent
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I understand
that there is a cancellation fee for non attendance or cancellation with less than 1 business days’ notice of any appointments.
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Consent
*
I understand
that if I fail to attend my appointment without notice or with less than 1 business days notice I will be asked to pay for the missed consultation in full before rebooking an appointment. Extreme circumstances will be considered and will have to be proven to avoid this fee.
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Consent
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I understand
that $50-100 deposit will be taken when you book your initial appointment which is non refundable (see terms and conditions).
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Consent
*
I understand
that I am free to discuss this treatment with other healthcare practitioners and continue to see my regular GP and specialist.
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Consent
*
I understand
if I stop attending the clinic I will need to stop all supplementation and seek alternative care from another practitioner.
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Consent
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I understand
that the doctor does not do insurance claims, health fund claims, Centrelink or medical certificates nor prescribe any drugs of addiction.
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Consent
*
I understand
that results of testing will NOT be released until a follow up consultation has occurred with us and results explained by the doctor.
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Consent
*
I understand
that if I require my results or records to be transferred to another doctor, I will need to provide a transfer of medical records form from that doctor and a fee will need to be paid based on AMA rates $38 for 33 pages or less + $1.40 per page if more than 33 pages +GST for a hard copy. Electronic copies can be emailed for $60 +GST.
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Consent
*
I understand
follow up consultations’ costs are time based, privately billed and subject to change at the discretion of the doctor; Please contact the practice to confirm practice fees.
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Consent
*
I understand
that I will have to wear a mask during the consult, and I will be temperature checked. If you present to this practice with a fever or respiratory symptoms, you will be asked to provide a rapid antigen test at your own cost or covid 19 pcr test which is recent less than 48 hours old. It is our medicolegal right to protect our staff. You will also be asked to wear a mask.
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Consent
*
I understand
that it is my responsibility NOT to attend this clinic with a fever or respiratory symptoms and may be refused consultation until COVID 19 has been excluded. The appointment will be cancelled, and I will be charged the full fee of the consult if this scenario arises and the doctor is unable to see me.
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Consent
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I understand
that any behaviour deemed aggressive, threatening, or insulting to any practice staff member immediately disqualifies me from the practice as it deems the doctor patient relationship untenable. This will be determined by the Director of the practice.
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Consent
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I AGREE TO THE TERMS AND CONDITIONS
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Signature
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Patient is under 16 years of age. parents or carers signatures required.
Parent / Carer 1 Signature*
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Parent / Carer 2 Signature*
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Comments
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