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Two Kidneys

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  • Phone : 02 4321 0555
  • Fax : 02 4321 0125
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Forms

Patient Information Form

Dr Karthik Kumar · Consultant Nephrologist

Patient Information Form

Please complete your details and the health questionnaire before your first appointment.

  1. 1Personal Details
  2. 2GP, Medicare & Health Cover
  3. 3About Your Health
  4. 4Privacy & Consent

Required fields

Personal Details

It is important that you contact us if there are any changes to your contact details.

Torres Strait Islander

Aboriginal

GP, Medicare & Health Cover

Female patients: Do you require a female staff member to be present for the initial examination?

Pathology requested by Dr Kumar can be done at any pathology company of your preference.

About Your Health

Please fill in as much as you can as this helps us in helping you.

Please choose which is appropriate, 5 being the worst.

1. Have you had a loss of appetite, tiredness, shortness of breath?

2. Have you noticed swelling in your legs?

3. Have you had chronic headaches, palpitations, heat or cold intolerances, recent un-intentional weight gain or loss, or postural symptoms? (Select any)

4. Have you seen blood in the urine?

5. Do you get up in the night to pass urine?

6. Have you had kidney stones?

7. Have you had difficulty in passing urine?

Are you incontinent of urine?

8. Have you had frequent urinary tract infections?

9. Have you had joint pains / mouth ulcers / rash?

Which ones?

10. Have you had any bone pains or fractures?

11. Have you had recent CT scans or angiogram?

12. Have you had anti-inflammatory drugs?

13. Have you had any alternative / herbal medicines in the past?

14. Pregnancy (if applicable)

15. Family history of (select any)

16. Have you been a smoker?

17. Do you drink alcohol?

Privacy & Consent

PRIVACY POLICY: Dr Kumar may release personal/medical information collected under appropriate circumstances to the following: Your referring doctor or any other medical practitioner involved in your care, pathology and/or radiology service, in emergency situations to any person or body deemed necessary e.g.: Emergency department doctors, Health funds and/or worker compensation bodies, medical research studies.

PERSONAL INFORMATION CONSENT: I hereby consent to the collection and use of my personal information, including those circumstances listed above, for the purpose of my care and wellbeing, in accordance with the reporting requirements under legislation and/or collection of any outstanding accounts.

Patient’s Signature

Date
06/11/2026

Your details are sent securely and kept confidential.