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Form library · AH-002

Allied health history and medications

Example only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. This example has not had a separate legal review.

Rules differ by state; check yours.

Allied-health clinics asking about conditions, medicines, allergies and injuries.

A short history the practitioner reviews before the first visit. It asks about conditions, medicines, allergies, pregnancy and past injuries. It is not a diagnosis and it is not a government health record.

Physio and allied health at nopen

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Allied health history and medications

Example only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. This example has not had a separate legal review.

Example only. Fictional clinic: Example Allied Health Clinic, Subiaco. A yes answer does not decide treatment.

Tell us if any of these apply
Are you pregnant?
Do you take a medicine that affects bleeding?
Do you have an implant, such as a pacemaker or a joint replacement?

Privacy: Example Allied Health Clinic collects this information to provide your care. We may share it with the people who treat you. Read our privacy policy at example.com/privacy. Example only: the practice must write its own collection notice. See GEN-002.

Fields

  • Conditions

    A checklist, plus a free-text other.

  • Medicines

    What they take now, in their own words.

  • Allergies

    Reactions, in their own words.

  • Pregnancy, bleeding and implants

    Three yes or no questions.

  • Injuries

    Past injuries and surgery, in their own words.

  • Health information

    A tick. The practice collects the health information on the form for care.

  • Collection notice

    A line the practice writes before anyone uses the form.

  • Signature

    Signed on the phone.

Questions

Does a yes answer decide treatment?

No. It tells the practitioner to read the answer. The form does not decide treatment.

Can I change the checklist?

Yes. Choose minor changes and say what to add. Use as is has no setup fee.

About these templates

These templates are examples only, to help you get started. They are general information, not legal, medical, clinical or professional advice, and they may not suit your business, your profession or your state or territory.

Before you use any template, you must review and adapt it, and have it checked where needed, so it fits your services, your professional body's rules, privacy and health records laws, and the law where you operate. This matters most for consent, waiver, privacy and minors' forms. You are responsible for the forms you use and the information you collect.

To the extent the law allows, nopen gives no warranty that the templates are complete, current or fit for any purpose, and is not liable for loss arising from their use. Nothing here excludes, restricts or modifies any right or remedy you have under the Australian Consumer Law that cannot lawfully be excluded.

The templates are not endorsed by or connected with any government agency, including Services Australia, Medicare or the NDIA. Do not add government logos, the Commonwealth Coat of Arms or other official marks to them. Fields that refer to government numbers (such as a Medicare card number) are labels only.

Example only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. This example has not had a separate legal review.