Patient Details

Progressive Longevity - New Patient Assessment

Thank you for your interest in Longevity Medicine at Progressive Sports Medicine. Please complete the following assessment to help us understand your health background and goals. The expected completion time is 20-30 minutes. If you need to come back you can click "Save and Complete Later" at the bottom of any page. Please have your Medicare card, medication and supplement list, details of recent investigations at hand.

Note: Completing this form does not guarantee an appointment - our team will review your submission and contact you to confirm a booking.

For further information about Longevity Medicine before completing this form, please visit: http://www.progressivespecialists.com.au/longevity-consultation

Patient Details

Title *

Patient First Name *

Patient Last Name *

Which of the following statements best describes your circumstance: *

I will be a new patient to Progressive Sports Medicine, interested in pursuing Longevity Medicine.I am an existing patient at Progressive Sports Medicine.

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

Longevity Medicine consultations are focused on evidence-based preventive health and longevity optimisation. If you have a musculoskeletal condition requiring specialist assessment, a separate Sports Medicine consultation can be arranged.

Do you have any musculoskeletal conditions currently affecting your ability to exercise? *

YesNo

If unsure, please contact us on (02) 8540 8019.

Do you need step-free access (no stairs) at our practice? *

NoYes (our administration will allocate a ground-floor room)

Residential Address Lookup *

Start Typing Your Address Here to Auto-populate Below Fields: *

Suburb *

State *

Postcode *

Date of Birth *

Mobile Number *

Gender *

MaleFemaleOther

Occupation

Email Address *Please enter this carefully as we communicate via email

Next of Kin (NOK) Name *

NOK Relation to You

NOK Mobile/Phone Contact Number *

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 currently registered with Medicare.

Patient's Medicare Card Number *

Patient's Medicare Card Expiry *

Patient's Medicare Card IRN *The number before the patient's name on the card.

Parent/Guardian Medicare Card IRN *The number before your name on the Medicare card.

Parent/Guardian Salutation *

Parent/Guardian Full Name *

Parent/Guardian Date of Birth *

Parent/Guardian Address (If Different From Patient)

Longevity Goals

Your Longevity Medicine Goals

What aspect/s of Progressive Longevity most appeal to you? *

Metabolic Health (weight, insulin resistance, glucose control, diabetes prevention)Cardiovascular Health (blood pressure, cholesterol, heart disease prevention)Body Composition (fat loss, muscle preservation)Exercise & Physical FitnessSleep, Recovery & WellbeingPreventative Health & ScreeningOther factor/s

What other factor/s have flagged your interest in our Clinic?

Please outline what you personally hope to achieve with our guidance? *

Musculoskeletal Information

Musculoskeletal Condition Information

Please mark the location of any musculoskeletal conditions on the body map below. *

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 or conditions? *

Investigations

Your Medical Investigation History

At Progressive Longevity, our approach utilises a multi-system assessment framework to individualise your care. We ask you to provide as much relevant detail regarding your medical history in this section, as your future treatment may be informed by past longevity-relevant investigations you've undertaken, including:

Medical imaging (e.g CT and MRI)
Cardiovascular testing (e.g. echocardiogram, cardiac stress test)
Cardiorespiratory fitness results (e.g. VO₂ max or aerobic threshold test)
Sleep studies
Specialist physician consultations (e.g. cardiologist)

Please provide this information in the relevant fields below.

Note: If you have multiple investigations with the same organisation or practitioner, you may denote this by writing "multiple" in the "Date (Month/Year)" to save time listing each investigation individually.

Investigation Type

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.

Note: You may omit this section if the information is included on your valid GP referral.

Anatomical Location (inc. side)

Operation Name

Month/Year

Medications & Supplements

Your Current Medications and Supplements

Please list your current medications and supplements. This information helps us to identify any present side effects and/or medication interactions, and also allows your clinician to identify lower-value supplements in consideration of your broader longevity picture.

Note: You may omit this section if the information is included on your valid GP referral.

Your Known Allergies

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

YesNo

Note: You may omit providing allergen information if it is included on your valid GP referral.

Name/Compound

Reaction (If known)

Medical History

Your Family History

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

Please indicate if you're adhering to any of the following dietary protocols: *

Please detail any other dietary protocol/s you're adhering to:

If you have a medical/restrictive diet please provide more details (E.g. avoiding nightshades for and inflammatory condition)

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

How many hours of sleep do you get each 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 (this is the intensity of exercise that makes a 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

Understanding your mindset and any challenges helps us to give you the best opportunity for better healthspan.

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 your 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 *

Terms, Conditions, Privacy 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, please read our practice Privacy Policy: https://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.

Your participation in the Progressive Longevity Program is governed by the Progressive Longevity Program Terms and Conditions, which include the nature and limits of the service, fees and cost estimates, communication and response times, urgent care advice, and the terms for the Progressive Longevity app. The current version, as dated on the page, is available here: https://www.progressivespecialists.com.au/longevityterms-conditions

Furthermore please indicate via signature your comprehension of the following:

I have read and agree to the Progressive Longevity Program Terms and Conditions (current version as dated at the link above).
I understand the program is not an emergency or on-demand service, and that if I am acutely unwell I will contact my GP, call 000, or attend the nearest emergency department.
I confirm I am 18 years of age or older.
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 agree to Progressive Sports Medicine's Privacy, Information Use and Consent policies and the Progressive Longevity Program Terms and Conditions

I have read and agree to Progressive Sports Medicine's Practice Privacy, Information Use and Consent policies: *

Draw signature|Type signatureClear

Your Full Name *

Date *

Practice Policies

Practice Booking and Cancellation Policy

Cancellation 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 may require a 50% deposit. The 50% late cancellation fee will apply if cancelled within 2 business days, meaning forfeiture of the deposit.

Our complete booking and cancellation policy is viewable via the following link: http://www.progressivespecialists.com.au/fee-page.

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

Draw signature|Type signatureClear

Your Full Name *

Date: *

Save and Complete Later