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Please fill out this form and bring it with you to your first appointment     Download Form

Confidential
Dr. Tim Bajraszewski
MB. BS. FRACGP. FACNEM.
Dip. Germ.EAcP.

Medicare Number 
Surname
Given Names
Full Address
Tel. home
Tel. Business
Date (Today)  dd / mm / yyyy
Date of Birth dd / mm / yyyy
Country of Birth
Marital Status        Sex Male Female
Next of Kin
Occupation
Employer/School
Blood Group Ph:
 
  Family History
 
Age
Illness and Problems
If dead, cause of death
Age at death
         
  Father
  Mother
  Brother 1
  Brother 2
   
  Sister 1
  Sister 2
   
  Spouse
   
  Others
 
 
 
What problems [including operations] have you had in the past?
 
What problem[s] are you seeking help for now?
 
 
 
Do you suffer from any of the following [please tick]  
     
Thrush
Asthma
Hay fever
Eczema
Acne/Skin problems
Heart problems
High blood pressure
High cholesterol
Strokes
 Menstrual problems
Menopause problems
Arthritis/Joint problems
Indigestion
Stomach ulcers
Haemorrhoids
Diabetes

Cancer
Constipation
Kidney problems
Bladder problems
Eye problems
Ear problems
Sinus problems
Fatigue
Diarrhea
     
What medications are you taking at present [include vitamins, herbs, oral contraceptives] 

For women – date of last pap smear:

 
Do you smoke?    
Are you happy with your weight?
   
Do you watch what you eat?
 Do you drink alcohol?
   
Are there foods that you crave for or eat a lot?

 Do you work with any chemicals?
Do you exercise regularly?
 Do you sleep well?
   
  Do you prefer natural remedies?
Please feel free to supply any additional information and bring along any relevant blood tests and x-rays to your consultation if available.
 
 
 
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