Patient Details

CONFIDENTIAL PATIENT REGISTRATION FORM

Patient Details

Salutation *

First Name *

Last Name *

Choose one of the following: *

New Patient for the SpecialistExisting Patient with a New Area of Concern for the Specialist

Reason for Referral & Areas for Treatment *Medicare rebates require a current GP referral for new conditions or if your last referral and consult is more than 9 months ago.

Address

Street

Suburb

State

Postcode

Date of Birth

Mobile Number

Gender

MaleFemaleOther

Cultural Identity: Do you identify as

Aboriginal or Torres Strait IslanderNeitherPrefer not to say

Occupation

EmailPlease enter this carefully as we communicate via email

Medicare Number

Expiry

Line Ref Number

Practice Privacy Policy

This practice is, as a health provider in the private sector, bound by the National Privacy Principles and the Health Records and Information Privacy Act 2002 (NSW). These Principles set the standards by which personal information is collected from patients. A copy of these Principles is available from the Department of Health or the Australian Medical Association.

As part of your treatment, it is usual to write to your referring Doctor, the Physiotherapist involved in your care, and any other Specialists you are referred to, including imaging results, etc.

In the case of compensation matters, it may be necessary to write to the Insurers, Solicitor, Employer and/or rehabilitation provider. As outlined in the guidelines above, only the necessary information will be released.

For quality assurance and research, information may be extracted from your record and held on a specific secure database on occasion. It may be necessary for us to contact you for an ongoing assessment.

Unless otherwise indicated

I HEREBY AUTHORISE THE RELEASE OF MY MEDICAL HISTORY TO MY FAMILY DOCTOR/INSURANCE COMPANY/SOLICITOR (WHERE APPLICABLE).

I HAVE READ AND UNDERSTAND THE FEE AND CANCELLATION POLICY

https://www.progressivespecialists.com.au/fee-page

I AGREE TO TAKE RESPONSIBILITY FOR THE PAYMENT OF ALL ACCOUNTS, PRIVATE OR INSURANCE.

Signature *

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Printed Name

Date

Third Party

Is this a current Workers Compensation or Third-Party Claim? *

Yes No

Insurer Details

WORKER'S COMPENSATION OR THIRD PARTY CLAIM DETAILS

Insurance Company

Claim Number

Contact Person (Case Manager)

Case Manager Email

Rehab Coordinator (if applicable)

Rehab Coordinator Email

Employer

Injury Details (Date, Place, Brief Description)

Condition

Are you seeing us about Weight Loss or Metabolic Health? *

YesNo

If yes, you will need a "metabolic appointment" and any associated musculoskeletal issues must be assessed in more detail in a separate consult

Medical

On the body map please mark the LOCATION of your current problem (if relevant) *

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How long had you had this problem and was there an incident?

INVESTIGATIONS: LIST ALL RELEVANT INVESTIGATIONS

Test Type

Company/Suburb

Date (Month/Year)

Test Type

Company/Suburb

Date (Month/Year)

What TREATMENT have you had to date?

EXERCISE BACKGROUND & HABITS

What ACTIVITIES or EXERCISE do you enjoy most?

Exercise Modes

Intensity

Frequency

Duration

MEDICAL HISTORY: LIST ANY CONDITIONS REQUIRING TREATMENT OR SURGERY

You May Omit This Section If Providing an Up To Date GP Referral with Health Summary

Body Area

Treatment/Operation

Year

MEDICATIONS & SUPPLEMENTS

Please outline your current Medications and Supplements

List allergies (Medication/ Food/ Other):

Lifestyle

LIFESTYLE HISTORY- MANDATORY FOR ALL PATIENTS

Choose your answer

SmokerNon-SmokerEx-Smoker

Current alcohol intake (quantity/frequency)

Are you on a diet or trying to lose weight?

YesNo

Are you having any issues with sleep recovery?

YesNo

Have you had current/previous issues with mood/mental health?

YesNo

Have you had current/previous menstrual irregularity?

YesNo

METABOLIC HEALTH QUESTIONNAIRE

What is your primary reason for seeking care at Progressive Sports Medicine?

Other (please specify):

Other relevant family history:

Choose your answer:

SmokerNon-SmokerEx-Smoker

Alcohol Intake: frequency and quantity per week?

Other:

Are you actively trying to lose weight?

YesNo

Have you had current/previous menstrual irregularity? (Females only)

YesNo

SLEEP HEALTH

Average hours of sleep per night and usual bed time

Sleep Quality

PoorFairGoodExcellent

Do you feel refreshed on waking?

YesNo

Have you ever had a sleep study?

Yes No

Have you ever been diagnosed with Sleep Apnea or any other sleep disorder?

Yes No

PHYSICAL FITNESS FURTHER DETAILS

Estimated Zone 2 (lower intensity) aerobic exercise per week (minutes):

Do you use a fitness tracker or step-counter?

Have you ever performed a VO2 max test?

YesNo

HEALTH GOALS & MINDSET

Have you had current/previous issues with mood/mental health?

YesNo

On a scale of 1–10, how motivated are you to make health changes? (10 is highest)

What challenges (if any) do you foresee in implementing health changes?

Do you have a supportive environment (partner, friends, family)?

FABQ

How did you hear about our Specialist Clinic?

Please provide details

Referrer Details

Referral Letter

Browse

You can also email this to office@progressivespecialists.com.au

Other Clinicians involved in your Condition

PRIVACY:

We value our patients' privacy and adhere to the Australian Privacy Act. Review our Privacy Policy HERE

Practice Cancellation Policy

Cancellation & Attendance Policy

To maintain a high standard of care for all patients, we require a minimum of 2 business days' notice for cancellations or changes to appointments.

A 50% cancellation fee applies for missed appointments or changes with less than 2 business days' notice.
Further appointments cannot be booked until this fee is paid.
SMS reminders are sent 5 and 3 business days before your appointment to allow time to reschedule if needed.
Patients under third-party insurance are personally liable for late cancellation or no-show fees and will not be rebooked until paid.

Late Arrivals: If you arrive late, we may need to shorten or reschedule your appointment to avoid delaying other patients.

Prolonged Bookings: Appointments involving complex services that require over 60 minutes require a 50% deposit. The 50% late cancellation fee will apply if cancelled within 2 business days, meaning forfeiture of the deposit.

We appreciate your understanding and cooperation to help us deliver timely, high-quality care.

I have Read and Agree to the Cancellation Policy *

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