Patient Details

SPECIALIST LONGEVITY ASSESSMENT FORM

Patient Details

Salutation *

First Name *

Last Name *

Sport and Exercise Medicine (SEM) physician consultation booking type: *

New patient to Progressive Sports Medicine. Existing patient with pain/dysfunction in a new anatomical area or areas.Existing patient presenting for the same condition/s, >12 months since my last review.

Have your personal details changed since your last visit (e.g. address, Medicare card number, preferred email address)? *

YesNo

Reason for Referral & Areas for Health Optimisation *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

Do you identify as:

Aboriginal/Torres Strait IslanderNeitherPrefer not to disclose

Occupation

Email AddressPlease enter this carefully as we communicate via email

Next of Kin (NOK) Name

NOK Relation to You

NOK Mobile Phone Number

Medicare Number

Medicare Card Expiry

Medicare Line Reference 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.

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 Privacy Policy

Privacy, Information Use and Consent

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). 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.

-I understand how my personal and health information may be used and disclosed as outlined above.
-I consent to being contacted via SMSfor follow-up and outcome assessment related to my care (PSM Research).
-I have read and understand the Fee and Cancellation Policy:https://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 *

Msk Problems

Do you have any Injuries or Musculoskeletal problems affecting your capacity for Exercise? *

YesNo

If significant, associated musculoskeletal issues may need to be assessed in more detail in a separate Sports Medicine consult

Msk Details

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? *

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

To help us provide the most suitable consulting room, 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

What INVESTIGATIONS have you had to date?

What TREATMENT have you had to date?

Medical & Family

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):

Metabolic Health

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?

YesNoPrefer not to say

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 minutes of zone 2 aerobic exercise per week (zone 2 being aerobic activity that allows you to maintain a conversation):

Do you use a fitness tracker or step-counter?

Have you ever performed a VO2 max test?

YesNo

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

YesNo

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

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)?

Referral & Policy

How did you hear about our Specialist Clinic? *

Please provide relevant details

Which practitioner is referring you to our specialists? *

What suburb is their clinic located in? *

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 your GP or specialist physician? *

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

Do you have any other health practitioners involved in your treatment? (e.g. physiotherapist, chriopractor, osteopath). *

YesNo

Please include their name, profession and practice suburb. *

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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