Re:You Health provides administrative support and facilities to the private practices of our bariatric medical practitioners

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Patient Registration Form

Please, make sure you have contacted us to book an appointment before you fill out the below new patient registration form.

Have you booked an appointment?

Download New Patient Registration Form (PDF)

Patient Details

Title

What gender do you identify as?

Family name

Given names

Preferred name

Pronouns

DOB

Ethnicity

Occupation

Aboriginal / Torres Strait Islander?

Address

Street Address

Suburb

State

Postcode

Postal Address

Address

Suburb

State

Postcode

Contact Details

Mobile phone

Home phone

Do you give permission for this email/phone number to be used to contact you regarding your treatment/appointments/reminders?

Yes

Emergency Contact

Name

Relationship

Mobile phone

Regular GP Details

Doctors Name

Practice Name

Practice Suburb

Other Doctors and Specialists

Doctor's Name

Practice Name

Speciality

Doctor's Name

Practice Name

Speciality

Doctor's Name

Practice Name

Speciality

How did you hear about us

Insurance

Do you have a Medicare number?

Yes

Unsure

Do you have a DVA card?

Yes

Unsure

Do you have private health insurance?

Yes

Unsure

Concession

Do you have a Concession card?

Yes

Medical History

Please indicate if you have or have had any of the following medical conditions:

Have you been diagnosed with insulin resistance diabetes?

Yes

Unsure

Have you been diagnosed with pre-diabetes?

Yes

Unsure

Have you been diagnosed with diabetes?

Yes

Unsure

Have you been diagnosed with gestational diabetes?

Yes

Unsure

Have you been diagnosed with Polycystic Ovary Syndrome (PCOS)?

Yes

Unsure

Do you have fertility issues?

Yes

Unsure

Do you have menstrual issues?

Yes

Unsure

Do you have gynaecological issues?

Yes

Unsure

Have you been diagnosed with thyroid disease?

Yes

Unsure

Have you been diagnosed with high blood pressure?

Yes

Unsure

Have you been diagnosed with heart disease?

Yes

Unsure

Have you been diagnosed with atrial fibrillation?

Yes

Unsure

Have you been diagnosed with high cholesterol?

Yes

Unsure

Have you been diagnosed with liver disease?

Yes

Unsure

Do you have joint or mobility issues?

Yes

Unsure

Have you been diagnosed with arthritis?

Yes

Unsure

Have you been diagnosed with sleep apnoea?

Yes

Unsure

Have you been diagnosed with asthma?

Yes

Unsure

Have you been diagnosed with reflux?

Yes

Unsure

Have you been diagnosed with clotting disorders?

Yes

Unsure

Do you have a history of blood clots?

Yes

Unsure

Have you been diagnosed with depression?

Yes

Unsure

Have you been diagnosed with anxiety?

Yes

Unsure

Have you been diagnosed with any other psychiatric disorders?

Yes

Unsure

Have you ever had cancer?

Yes

Unsure

Do you have any other medical history relevant to your care?

Surgical History
Please detail any past non-bariatric operations, particularly abdominal

Procedures and dates

Have you previously had any type of bariatric surgery or endoscopic procedure for weight loss?

Yes

Family History
Please detail any illnesses in your immediate family (i.e. parents, siblings) e.g. diabetes, heart disease, stroke, high cholesterol, blood pressure, clots.

Procedures and dates

Medications
Please state all medications that you are taking

Medication

Dose

Reason for taking

Duration

Medication

Dose

Reason for taking

Duration

Medication

Dose

Reason for taking

Duration

Medication

Dose

Reason for taking

Duration

Medication

Dose

Reason for taking

Duration

Medication

Dose

Reason for taking

Duration

Medication

Dose

Reason for taking

Duration

Medication

Dose

Reason for taking

Duration

Supplements/over the counter medication

Allergies

Allergy and nature of reaction

Smoking History

Do you smoke?

Yes

Ex-smoker

Alcohol History

On average how many standard drinks do you have per week?

How many nights per week do you drink?

Weight Loss Attempts

Which of the following have you tried?

Diets (please specify)

Meal replacements / shakes

Weight loss medications (please specify)

Exercise programs (please specify)

Weight Loss History

What has been your heaviest (non-pregnant) weight?

When?

What has been your lightest adult weight?

When?

At what weight have you felt most comfortable?

What is the maximum amount of weight you have been able to lose and by what method?

When?

Eating Patterns

Do you eat regular meals?

Do you crave food?

Are you always hungry?

What are the eating behaviours you would most like to change?

Activity Levels

Are you regularly physically active?
If yes, what do you do and how often?

Privacy

Please click here to view our Privacy Statement.

I certify that I have read and understood the Re:You Privacy Statement on their website and consent to my personal information being collected, stored, used, disclosed and accessed as outlined in that Statement.

I understand that I am not obligated to provide any information requested of me, but that a failure to do so may compromise the quality of care and treatment provided.

I authorise Re:You to send text messages for treatment, appointment reminders, and information via email from time to time.

I have reviewed Re:You’s fees outlined on their website, and I accept responsibility for any accounts arising from Re:You services. I am aware that I can contact Re:You to clarify any questions concerning fees.

I understand that for consultations that do not attract a private fee, I agree for the benefit to be assigned to Medicare.

Name

Date

Signature

Security

Patient Registration Form

Patient Details

Address

Postal Address

Contact Details

Emergency Contact

Regular GP Details

Other Doctors and Specialists

How did you hear about us

Insurance

Concession

Medical History

Surgical HistoryPlease detail any past non-bariatric operations, particularly abdominal

Family HistoryPlease detail any illnesses in your immediate family (i.e. parents, siblings) e.g. diabetes, heart disease, stroke, high cholesterol, blood pressure, clots.

MedicationsPlease state all medications that you are taking

Allergies

Smoking History

Alcohol History

Weight Loss Attempts

Weight Loss History

Eating Patterns

Activity Levels

Privacy

Surgical History
Please detail any past non-bariatric operations, particularly abdominal

Family History
Please detail any illnesses in your immediate family (i.e. parents, siblings) e.g. diabetes, heart disease, stroke, high cholesterol, blood pressure, clots.

Medications
Please state all medications that you are taking