Patient Details & Considerations

Specialist-Led Longevity Medicine 3.0 Candidacy Form

If you haven't already done so, please read patient information about Longevity at Progressive Sports Medicine, available at: http://www.progressivespecialists.com.au/longevity-consultation

Patient Details

Patient Salutation *

Patient First Name *

Patient Last Name *

Please detail which salutation you prefer *

Which of the following statements best describes your circumstance: *

I will be a new patient to Progressive Sports Medicine, and am interested expressly in pursuing Longevity Medicine 3.0.I am an existing patient at Progressive Sports Medicine, and have been recommended for Longevity Medicine 3.0.

Have any of your personal details changed since you last visited Progressive Sports Medicine? This includes your address, Medicare card number, preferred email address or most suitable contact number. *

YesNo

Musculoskeletal Condition Considerations

If you're:

1) Seeking a sport and exercise medicine specialist assessment for musculoskeletal concern/s; or

2) Significantly affected by musculoskeletal condition/s* that you believe will affect your engagement in Longevity 3.0,

Please instead complete this form. This will ensure you're booked for a more appropriate consultation at Progressive Sports Medicine: http://www.progressivespecialists.com.au/new-patient-form

*Muskuloskeletal conditions to consider include, but are not limited to, unmanaged and/or debilitating joint pathology (e.g. osteoarthritis), tendon pathology (e.g. shoulder rotator cuff tear), spinal conditions (e.g. disc herniations), instability conditions (e.g. hip dysplasia) or muscle injuries/weakness syndromes (e.g. acute-on-chronic muscle strains or significant atrophy) or chronic pain conditions (e.g. fibromyalgia).

With this in mind, do you have any injuries or musculoskeletal conditions that are presently significantly affecting your ability to exercise? *

YesNo

If you're unsure whether your health condition/s will impede your ability to engage with Longevity 3.0, please contact us on (02) 8540 8019 or via email at office@progressivesportsmedicine.com.au for assessment.

To help us provide the most suitable consulting room for your appointment, do you have any difficulty with using stairs, or do you otherwise require step-free access when visiting our practice locations? *

Yes (Our administration will allocate a ground-floor room)No

Residential Address Lookup *

Start Typing Your Address Here to Autopopulate Below Fields: *

Suburb *

State *

Postcode *

Date of Birth *

Mobile Number

Gender *

MaleFemaleOther

Occupation

Email AddressPlease enter this carefully as we communicate via email

Next of Kin (NOK) Name *

NOK Relation to You

NOK Mobile/Phone Contact Number *

Medicare Number

Medicare Card Expiry

Medicare Line Reference NumberThis is the number before your name on your Medicare card.

Do you receive your Medicare rebates personally, or does a parent/guardian receive them on your behalf? *

I receive my Medicare rebates.A parent/guardian receives them on my behalf.I am Medicare ineligible or otherwise not presently registered with Medicare.

Parent/Guardian Salutation *

Parent/Guardian Name *

Parent/Guardian Date of Birth *

Parent/Guardian Medicare Card Individual Reference Number *

Parent/Guardian Address (If Different From Patient)

Practice Policies

Practice Privacy, Information Use and Consent

Please read this section carefully before signing.

Our practice complies with Australian privacy law, including the Australian Privacy Principles and the Health Records and Information Privacy Act 2002 (NSW). Your personal and health information is collected, used, and stored securely to provide medical care. This may include sharing relevant information with other health professionals involved in your care (such as your referring doctor, physiotherapist, specialists, and imaging providers). For more information about our practice privacy policy, please follow this link: http://www.progressivespecialists.com.au/privacy-policy

Where your care relates to a compensation or insurance matter, relevant information may be provided to insurers, solicitors, employers, or rehabilitation providers, limited to what is necessary and appropriate.

From time to time, de-identified information may be used for quality assurance, clinical audit, or research purposes, and we may contact you for follow-up or outcome assessment.

To support high-quality care, we use secure AI-assisted transcription (Lyrebird AI) during consultations. Audio may be recorded solely to generate a clinical note, which is reviewed and approved by your clinician. Recordings are processed securely, accessed only by authorised staff, not used for marketing or non-clinical purposes, and not retained beyond what is required for documentation. You may withdraw consent for AI-assisted transcription at any time without affecting your care.

Furthermore please indicate via signature your comprehension of the following:

I understand how my personal and health information may be used and disclosed as outlined above.
I consent to being contacted via SMS for follow-up and outcome assessment related to my care (PSM Research).
I have read and understand the Fee and Cancellation Policy: http://www.progressivespecialists.com.au/fee-page
I agree to take responsibility for payment of all accounts, private or insurance.

Signature *

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Your Full Name *

Date *

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.

Our complete cancellation policy is viewable on our website via the following link: http://www.progressivespecialists.com.au/fee-page. We appreciate your understanding and cooperation to help us deliver timely, high-quality care.

I have Read and Agree to Progressive Sports Medicine's Cancellation Policy *

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Your Full Name *

Date: *

Longevity Experience

Your Longevity 3.0 Ambitions

What other factor/s have piqued your interest in Longevity Medicine 3.0? *

Please outline, with as much detail as you deem necessary, what you hope to achieve with Longevity Medicine 3.0. *

Musculoskeletal Information

Musculoskeletal Condition Information

On the body map below, please mark the location/s of your current muskuloskeletal condition/s. *

Clear drawing

How long had you had this condition/s? *

Was there a precipitating event relevant to your injury (e.g. fall or acute sports injury)? If so, please provide details. *

What therapies have you undertaken to alleviate this condition? *

Investigations

Your Medical Investigation History

The Longevity Medicine 3.0 consultation model at Progressive Sports Medicine utilises a comprehensive, multi-system assessment framework to identify early disease risk, quantify physical capacity, and guide targeted intervention to formulate your individualised longitudinal care plan.

For this reason, we ask you to please provide information pertaining to previous longevity-relevant testing you may have previously undertaken by providing information in the sections below. Relevant investigations include:

Medical imaging (including CT, MRI, X-rays and ultrasounds)
Cardiovascular testing (e.g. ECG, stress testing)
Cardiorespiratory fitness results (e.g. VO₂ max or aerobic threshold assessment)
Sleep studies
Specialist physician consultations, including cardiology, rheumatology, sleep physician and endocrinology

NB: If you have many medical scans with the same organisation, or consultations with the same clinic/practitioner, you may list "multiple" in the "Date (Month/Year)" as a single entry to save time inputting additional data.

Investigation (E.g. MRI, endocrinologist consultation, etc.)

Company or Practitioner

Clinic Suburb

Date (Month/Year)

Your Pathology Investigation/Bloodwork History

Have you had bloodwork/pathology screening conducted within the last six (6) months? *

YesNo

If "Other" please provide details so we may acquire your results: *

Your Surgical History

Previous surgeries provide critical insight into a patient’s structural history and future risk profile. They often reflect underlying joint degeneration, injury patterns, or systemic conditions that can directly impact how someone moves, loads, and responds to exercise.

In a longevity consultation at Progressive Sports Medicine, this information helps us tailor safe, effective training strategies, anticipate limitations, and prevent re-injury, ensuring the patient can maintain consistent, high-quality physical activity, which is one of the most important drivers of long-term health and performance.

Please provide any relevant information by completing the section below:

Anatomical Location (inc. side)

Operation Name

Month/Year

Medications & Supplements

Your Current Medications and Supplements

Understanding your medications and supplements is essential in a longevity consultation because it provides a real-world snapshot of your current physiology, risks, and behaviours. It allows your physician to identify drivers of weight change, fatigue, or metabolic dysfunction, uncover potential side effects or drug-nutrient interactions, and ensure that any exercise or nutrition strategy is both safe and effective from your initial consultation.

Just as importantly, it helps our multidisciplinary team (MDT) pinpoint unnecessary or low-value supplements and align everything you're presently taking with a clear, evidence-based plan. This way, your MDT won't just add interventions, but will have sufficient information to optimise your whole system for long-term health and performance.

Please provide as much information as possible via the relevant sections below.

NB - Please feel free to omit this section if the information is included on your valid GP referral.

Name/Compound

Dosage

Frequency

Reason

Your Known Allergies

Do you have any allergies? This may include allergies to medications, materials and foodstuffs. *

YesNo

NB - Please feel free to omit this section if the information is included on your valid GP referral.

Name/Compound

Reaction (If known)

Longevity Aspects

Your Family History

Please provide any additional family health history that you believe would be relevant to your Longevity 3.0 consultation.

Your Lifestyle Considerations

What is your current alcohol intake in standard drinks per week? *

What is your smoking status? *

SmokerNon-SmokerEx-Smoker

What is your average number of cigarettes/cigars/pipes smoked per week? *

What year did you cease smoking? *

Your Current Diet & Eating Habits

Are you actively dieting to lose weight? *

YesNo

Have you ever had concerns about your eating patterns or relationship with food, including periods of restriction, overeating, or weight cycling? *

YesNoPrefer Not to Disclose

Are you currently experiencing, or have you ever experienced, menstrual irregularity? *

YesNo

Your Sleep Health

What is your average hours of sleep per night? *

Do you have a regular bed time that you adhere to? *

YesNo

Do you experience regular sleep interruptions? (E.g. attending to a newborn or insomnia) *

YesNo

How would you rate your average sleep quality? *

PoorFairGoodExcellent

Do you wake up feeling refreshed? *

YesNo

Have you ever undertaken a sleep study? *

Yes No

Have you been diagnosed with sleep apnea or any other sleep disorder? *

Yes No

Your Present Fitness Regimen

What is your estimated minutes per week of zone 2 aerobic activity (zone 2 being aerobic exercise of sufficient intense to make conversation difficult, but not impossible): *

Do you use a fitness tracker or step-counter? *

YesNo

Have you ever performed a VO2 max test? *

YesNo

PAR-Q: Exercise Readiness

We include a 7-question pre-exercise screening questionnaire (PAR-Q) to ensure that any exercise recommendations are safe, appropriate, and tailored to your individual health profile. It helps us identify any underlying medical or musculoskeletal considerations that may influence how your body responds to training. This allows our team to prescribe exercise as a precise, effective intervention in accordance with your long-term health, performance, and longevity goals.

Please answer the following questions as honestly as possible below:

1) Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

YesNo

2) Do you feel pain in your chest when you do physical activity? *

YesNo

3) In the past month, have you had chest pain when you were not doing physical activity? *

YesNo

4) Do you lose your balance because of dizziness or do you ever lose consciousness? *

YesNo

5) Do you have a bone or joint problem that could be worsened by a change in your physical activity? *

YesNo

6) Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

YesNo

7) Do you know of any other reason why you should not do physical activity? *

YesNo

Your Health Mindset

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

YesNoPrefer Not to Answer

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)? *

Healthcare Team

Referrer Information and Your Healthcare Team

Has a medical practitioner referred you to our practice? *

YesNo

Which practitioner is referring you to our specialists? *

What suburb is their clinic located in? *

Do you have a GP that you regularly see? *

YesNo

What is the name of the GP that you see most regularly? *

What suburb is their practice located in? *

Do you have a referral from a general practitioner or specialist medical physician (E.g. cardiologist, orthopaedic surgeon)? *

YesNo

Please upload a copy of your referral letter here (Note: this document will save you time by consolidating your medical history and providing requisite information for your post-consult Medicare claim):

Browse

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

We also enquire about the other healthcare professionals involved in your care to ensure your longevity plan is coordinated, safe, and aligned with any existing treatments or conditions. This allows us to integrate our recommendations with your broader care team, avoiding duplication or conflict while optimising your long-term health outcomes. In accordance with our privacy policy, we will only share you health information with your relevant healthcare team members.

Please include information about other health professionals you're comfortable with our practice disseminating clinical correspondence to below:

Do you have any other health practitioners involved in your treatment? (e.g. cardiologist or exercise physiologist). *

YesNo

Practitioner Name *

Medical/Allied Health Profession *

Practitioner Suburb *

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