Step 1 of 2 50% Title:*DrMrMastMrsMissMsOtherPatient Surname:* Given Names:* (as appears on Medicare Card)Preferred Name: Sex:* Male Female Patient’s Street Address:* Street Address Suburb Postcode Patient’s Mailing Address: Mailing Address Suburb Postcode (if different from above)Date of Birth: Month Day Year Contact Phone Numbers:HomeWorkMobileContact Email Address:* Medicare Number: Ref: Expiry Date: DVA Number: Gold/White Card: Gold White Expiry: Work Cover Claim Reference: Private Fund Name: Membership Number: Level/Type of Cover: Hospital & Extras Hospital Only Extra Only Uninsured This information will help your doctor to understand your problem. Please complete the form as completely as possible. If you have any questions, do not hesitate to ask your doctor.Please tick one: Right foot/ankle Left foot/ankle Both feet/ankles If both, which is more painful? Right Left Please describe your problem:When did your symptoms begin? How did they begin?Are they? Improving Worsening Staying the same? Please describe your symptoms:Level of discomfort : 0 1 2 3 4 5 6 7 8 9 10 (Minimal to Severe)Where does it hurt? How would you describe the pain? ( ie: Sharp, Dull, Intermittent, Constant, Burning, Tingling, Throbbing, Other)Do you have any other symptoms? What makes your symptoms worse? What makes your symptoms better? Do you have any pains in any other joints? What treatment have you tried? Do you suffer from one of the following? (Tick all that apply) Rheumatoid Arthritis Psoriasis Ankylosis Spondylitis Enteropathic Arthritis Is there a family history of arthritis or psoriasis? Yes No Which? Other past medical history: (e.g. Diabetes Asthma, Blood Clots)Signature
