Elina Medical Weight Loss Clinic - Phone No : (03) 9581 2609
New Patient Registration Form - Please complete and submit prior to your appointment so you can be pre-registered.
If you prefer you can print the competed form and bring it along to your appointment, please arrive 15 mins early to allow time to enter your registration details into our system
Email address *
Patients Name *
First Name *
Surname *
Preferred Name:
Gender
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Date of Birth *
MM
/
DD
/
YYYY
Contact No. *
Address *
Post Code
Medicare Card Number
Ref Number on Card
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Expiry Date
Concession Card
Concession Card No.
Expiry Date
MM
/
DD
/
YYYY
Private Health Insurance
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Country of Birth
Ethnicity
Who is your usual GP?
Your General Medical History
Any medical conditions? Please List
Previous Surgery
Medications
Any Allergies - Please List
Food Intolerance / Preferences? eg Vegan, coeliac, pescatarian etc
Smoking
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PHYSICAL ACTIVITY
How active would you say you are currently?
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SLEEP
On average, how many hours of sleep do you get per night?
Do you snore?
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Has anyone told you that you stop breathing or have choking episodes overnight?
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WEIGHT HISTORY
Current weight (kg)
Current Height (cm)
What is your heaviest (non pregnant) weight (kg)
What is your lightest weight? (kg)
What is your ideal weight? (kg)
Is there a family history of overweight or obesity?
Clear selection
What weight loss tools have you tried in the past? (Please tick all that applies)
Medications You Have Tried:
WEIGHT LOSS SURGERY
Gastric banding? When?
Gastric bypass? When?
Sleeve gastrectomy? When?
Others?
Do you have a history of eating disorders? (eg. Anorexia, Bulimia)
Clear selection
HOW READY ARE YOU?
My greatest motivation to control my weight is..
On a scale of 0-10, how motivated are you to control your weight?
not at all motivated
extremely motivated
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On a scale of 0-10, how confident do you feel that you can manage your weight?
Not at all confident
Extremely confident
Clear selection
On a scale of 0-10, how often do you feel stressed, anxious or depressed?
None of the time
All of the time
Clear selection
Next of Kin
Who would we call in case of an emergency?
First Name
Surname
Address
Contact number
Relationship to the patient
How did you hear about us?
PRIVACY STATEMENT AND CONSENT FORM


Patient Health Information Consent.
To enable ongoing care and total quality improvement within this practice, and in keeping with the
Privacy Act 1988 and Australian Privacy principles (March 2014) we wish to provide you with sufficient
information on how your personal health information may be used or disclosed and record your consent
or restrictions to this consent Your personal health information will only be used for the purposes for which it was collected or as otherwise permitted by law and we respect your right to determine how your personal health information is used or disclosed.

The information we collect may be collected by a number of different methods and examples may
include: medical test results, notes from consultations, Medicare and health insurance details, data
collected from observations and conversations with you, and details obtained from other health care
providers (e.g. specialist correspondence).

By digital signing below, you (as a patient/guardian) are consenting, that on obtaining your personal contact
and health information it may be used or disclosed by the practice for the following purposes:

 Appointments/follow up reminder/recall notices/results for treatment and preventive healthcare
planning via letter, telephone or SMS.
 For accounting procedures and the collection of professional fees.
 The diagnosis and treatment of any health condition, including the communication of relevant
information only, to practice staff, specialists and other healthcare providers to ensure quality care is
provided.
 Accreditation and Quality Assurance activities are conducted by professionally trained non-treating
GP’s and other professionally trained and qualified persons e.g. General Practice Manager.
 For legal related disclosure as required by a court of law.
 For the purposes of research only where de-identified information is used.
 To allow medical students and staff to participate in medical training/teaching using only
de-identified information.
 For disease notification as required by law.
 For use when seeking treatment by other doctors in this practice.
At all times, we are required to ensure your details are treated with the utmost confidentiality. Your
records are very important and we will take all steps necessary to ensure they remain confidential.

I consent to the handling of my information by this practice for the purposes outlined , subject to any limitations on access or disclosure of which I notify this practice. *
Required
Glen Waverley, Bundoora, Hawthorn East & Berwick
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