• 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. 

  • Let's get to know you

    • Patient Information 

    • Patient information

    • Your contact details 

    • Contact details

    •  -
    • Medicare & Insurance details 

    • Medicare details

    • In case of emergency...
    •  -
    • Do you have private health insurance?
    • Who is you referring doctor? 

    • Referring doctor information

    • What worries you most? 

    • Your major concerns

    • What would you like to find out more about from Dr Mullins?

    • Help us understand a bit about you

    • Medicines 

    • Medicines information

    • Are you taking any medicines?*
    • Do you think you are allergic or get any side effects from medicines*
    • Home  

    • Home environment

    • Do you have any indoor pets?*
    • Do you have a damp mouldy house?*
    • Diet 

    • Diet and nutrition

    • What about diet?

    • For this next part, please list the amount of drinks that you have on an average day

  • The Problems You're Experiencing

    • Head 

    • Head, nose and sinus issues

    • Rows
    • Chest, breathing and heart 

    • Chest, breathing and heart

    • Rows
    • Stomach and kidneys 

    • Stomach and kidneys

    • Rows
    • Skin 

    • Skin

    • Rows
    • Food 

    • Food

    • Oral allergy syndrome: Do some foods give you any itchy mouth/throat the eaten like fruit or veggies ?*
    • Do you have suspected food allergy?*
    • Do you think you have food intolerance (e.g. bloating after wheat, migraines after chocolate/cheese, stomach upset from the sugars lactose in dairy or fructose in some fruit ?*
    • Other stuff 

    • Other stuff

    • Rows

  • Family History

    • Finished. Time to save and submit! 
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