New Patient Information and Consent Form
The Gut Guru practices in a Non-Judgmental and Confidential Manner with all Patients
Full Name
*
First Name
Last Name
Mobile
*
E-mail
*
1
Date of Birth
*
-
Day
-
Month
Year
Date Picker Icon
What is your Gender?
*
Male
Female
N/A
Patient History
Do you take regular medication?
*
Yes
No
If Yes, please list
Do you have any pre-existing Health Conditions The Gut Guru should be aware of?
*
Yes
No
If Yes, please list
Do you suffer from asthma?
*
Yes
No
Do you have any known allergies to Medications or Foods?
*
Yes
No
If yes please list
Do you regularly present with Symptoms of which you do not know the cause? If so, what are they?
*
Lifestyle
Do you believe your diet supports your Health?
*
Yes
No
Over the last 3 days, what have you eaten?
*
Be as specific as you can be
How many hours of sleep do you get?
*
How often do you exercise?
*
Everyday
5-6 Times per Week
2-4 Times per Week
Once per week
Never
Do you Smoke Tobacco?
*
Yes
No
If Yes, How many per Day?
Do you drink Alcohol?
*
Yes, Everyday
Yes, Often
Yes, Approx. Once Per Week
On Special Occasions
Never
Do you drink Caffeine?
*
Yes
No
If Yes, How much?
Outcomes
What goals are you trying to achieve?
*
What time frame have you given yourself to complete these Goals?
*
Health Insurance Information
Please be aware that not all Private Health Funds will cover this consultation. It is to their discretion, although you will be provided with a receipt and other relevent information if you wish to make a claim.
Medicare Number
*
Do you have Private Health Insurance?
Yes
No
Name of Fund
Type of Cover
Basic
Intermediate
Top
Member Number
Emergency Contact Details
Contact Person 1
*
Contact Number
*
Relationship
*
Contact Person 2
Contact Number
Relationship
Consent
Please answer the following questions regarding consent
Consent to The Gut Guru accessing my 'MyGov-My Health Record'
*
Allow
Do not Allow
Consent to The Gut Guru adding to my 'MyGov-My Health Record'
*
Allow
Do not Allow
Consent to The Gut Guru requesting pathology and other relevant results from my GP and/or Specialist
*
Allow
Do not Allow
Regular GP and/or Specialist
If you wish to allow The Gut Guru to liaise with your GP please enter their details to the best of your ability below
Name of Medical Practitioner
First Name
Surname Name
Role
Eg. GP, Specialty Field
Practitioner Address
Street Address
Street Address Line 2
City
State
Postal Code
Phone Number
I Agree
*
I have read, understood, acknowledge and confirm that the above information is true and correct
Additional Information
If there is any other information you wish to make The Gut Guru aware of please add here
Signature
*
Submit
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