Welcome!
Who is this form for?
If you are (or the patient is) over 10 years, please complete this Information Form.
If the patient is under the age of 10 years, please complete the Child Information Form.
What to do?
To help Dr Mullins to prepare for your consultation and to give him an idea of your important issues, you'll need to complete this Intake Form.
Please ensure that you complete this form at least 48 hours before your scheduled consultation (but preferably once you make an appointment).
Why?
Because you'll be able to hit the ground running (so to speak) and make the most out of your time with Dr Mullins. There will be a lot of information shared and a plan created for your next steps.
What to do?
1. Read the questions.
2. Answer the questions as best you can.
3. Hit submit.
How long will it take?
- Allocate between 5-15 minutes to complete
What do you need?
- Medicare card details for whoever is the patient being seen
- A list of medicines you are taking
*If you're completing this form on behalf of someone else, please note that the questions relate to the patient (not you) and should be answered about the patient's circumstances.

Your contact details
Contact details
E-mail
Best Landline Number:
Area Code Phone Number
Mobile number
Postal/home address:
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
OR Post Office Box details
Occupation*
If patient is under the age of 18 years, please provide each parents' name and date of birth (which will help us to submit your Medicare claim on your behalf if your are registered for this) plus best email and contact telephone numbers

Who is you referring doctor?
Referring doctor information
Who is your referring doctor and where do they work?*
If the referring doctor isn't your usual GP, who is the usual GP/medical centre that you usually visit?

Family History
Are there any major conditions that run in the family like allergy, celiac disease, arthritis or heart disease? If so, please list who is affected and by what?
How easy was it to complete this form?
How long did it take you to complete this form?
Please verify that you are human*

	No problem	Mild	Annoying
Eye irritation/watering
Hay fever
Poor sense of smell or taste
Sinus problems/surgery
Nasal polyps
Headaches or migraines
Tooth grinding or facial pain

	No problem	Past problem,not now	Mild	Current annoying issue
Stomach or peptic ulcer
Acid reflux or indigestion
Hepatitis or liver disease
Gallstones
Kidney disease or stones
Deafness or buzzing in the ears
Diagnosed coeliac disease
Diagnosed irritable bowel syndrome
Trouble swallowing or food getting stuck when swallowed
High blood pressure
High cholesterol
Bleeding from the bowel or significant recent weight loss

	No	Past issue, not now	Mild	Annoying
Hives/urticaria
Eczema/dermatitis
Contact allergic dermatitis (eg. metal, bandaids, cosmetics, plants)
Other skin issues

	No	Yes
Sugar diabetes
Stroke
Bad snoring or sleep apnoea
Significant daytime sleepiness
Major unintended weight loss in the last 6 months
Poor appetite
Low energy or mood
Sore muscle or joints (other than after going to the gym!)
Needing to go to the toilet more than once/night
Large local reactions to insect stings like bees or wasps
Dangerous reactions to insect stings (e.g.. all over rash, trouble breathing)

Welcome!

Let's get to know you