{"id":2170,"date":"2021-09-21T01:14:27","date_gmt":"2021-09-21T01:14:27","guid":{"rendered":"http:\/\/khoo.com.au\/?page_id=2170"},"modified":"2021-09-21T13:22:00","modified_gmt":"2021-09-21T13:22:00","slug":"patient-questionnaire","status":"publish","type":"page","link":"https:\/\/khoo.com.au\/index.php\/patient-questionnaire\/","title":{"rendered":"Patient Questionnaire"},"content":{"rendered":"\n<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-2232\"><form id=\"wpforms-form-2232\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"2232\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/2170\" data-token=\"9b0a9359f60f2afa13e6677ceaa9a364\" data-token-time=\"1776655782\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-2232-field_22-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-2232-field_22\">First Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2232-field_22\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][22]\" required><\/div><div id=\"wpforms-2232-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-2232-field_23\">Last Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2232-field_23\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][23]\" required><\/div><div id=\"wpforms-2232-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-2232-field_3\">Date of Birth <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2232-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" required><div class=\"wpforms-field-description\">dd\/mm\/yyyy<\/div><\/div><div id=\"wpforms-2232-field_4-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"4\"><label class=\"wpforms-field-label\">Identify as <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-2232-field_4\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2232-field_4_1\" name=\"wpforms[fields][4][]\" value=\"Male\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2232-field_4_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2232-field_4_2\" name=\"wpforms[fields][4][]\" value=\"Female\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2232-field_4_2\">Female<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-2232-field_4_3\" name=\"wpforms[fields][4][]\" value=\"Non-binary\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2232-field_4_3\">Non-binary<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-2232-field_4_4\" name=\"wpforms[fields][4][]\" value=\"Gender diverse\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2232-field_4_4\">Gender diverse<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-2232-field_4_5\" name=\"wpforms[fields][4][]\" value=\"Transgender\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2232-field_4_5\">Transgender<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-2232-field_4_6\" name=\"wpforms[fields][4][]\" value=\"Different identity\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2232-field_4_6\">Different identity<\/label><\/li><\/ul><\/div><div id=\"wpforms-2232-field_5-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"5\"><label class=\"wpforms-field-label\">Pronouns<\/label><ul id=\"wpforms-2232-field_5\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2232-field_5_1\" name=\"wpforms[fields][5][]\" value=\"She\/her\/hers\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2232-field_5_1\">She\/her\/hers<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2232-field_5_2\" name=\"wpforms[fields][5][]\" value=\"He\/him\/his\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2232-field_5_2\">He\/him\/his<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-2232-field_5_3\" name=\"wpforms[fields][5][]\" value=\"They\/them\/theirs\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2232-field_5_3\">They\/them\/theirs<\/label><\/li><\/ul><\/div><div id=\"wpforms-2232-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-2232-field_6\">Home address <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2232-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" required><\/div><div id=\"wpforms-2232-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-2232-field_7\">Suburb <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2232-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" required><\/div><div id=\"wpforms-2232-field_24-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-2232-field_24\">Post code <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2232-field_24\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][24]\" required><\/div><div id=\"wpforms-2232-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-2232-field_8\">Best contact number - mobile or landline  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2232-field_8\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][8]\" required><\/div><div id=\"wpforms-2232-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-2232-field_1\">Email Address <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-2232-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-2232-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-2232-field_9\">Medicare Number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2232-field_9\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][9]\" required><\/div><div id=\"wpforms-2232-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-2232-field_11\">Reference Number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2232-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" required><\/div><div id=\"wpforms-2232-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-2232-field_12\">Medicare Expiry Date <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2232-field_12\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][12]\" required><div class=\"wpforms-field-description\">mm\/yyyy<\/div><\/div><div id=\"wpforms-2232-field_13-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-2232-field_13\">Veterans Affairs Number (if applicable)<\/label><input type=\"text\" id=\"wpforms-2232-field_13\" class=\"wpforms-field-medium\" name=\"wpforms[fields][13]\" ><\/div><div id=\"wpforms-2232-field_18-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-2232-field_18\">Existing Medical Conditions (if any)<\/label><textarea id=\"wpforms-2232-field_18\" class=\"wpforms-field-medium\" name=\"wpforms[fields][18]\" ><\/textarea><\/div><div id=\"wpforms-2232-field_15-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-2232-field_15\">Medication list<\/label><textarea id=\"wpforms-2232-field_15\" class=\"wpforms-field-medium\" name=\"wpforms[fields][15]\" ><\/textarea><\/div><div id=\"wpforms-2232-field_17-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"17\"><label class=\"wpforms-field-label\">Smoking status <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-2232-field_17\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2232-field_17_1\" name=\"wpforms[fields][17][]\" value=\"Non-smoker\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2232-field_17_1\">Non-smoker<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2232-field_17_2\" name=\"wpforms[fields][17][]\" value=\"Ex-smoker\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2232-field_17_2\">Ex-smoker<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-2232-field_17_3\" name=\"wpforms[fields][17][]\" value=\"Smoker\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2232-field_17_3\">Smoker<\/label><\/li><\/ul><\/div><div id=\"wpforms-2232-field_16-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-2232-field_16\">Allergies (if any)<\/label><input type=\"text\" id=\"wpforms-2232-field_16\" class=\"wpforms-field-medium\" name=\"wpforms[fields][16]\" ><\/div><div id=\"wpforms-2232-field_21-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"21\"><label class=\"wpforms-field-label\">How did you find out about us?<\/label><ul id=\"wpforms-2232-field_21\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2232-field_21_1\" name=\"wpforms[fields][21][]\" value=\"Recommended by friend\/family\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2232-field_21_1\">Recommended by friend\/family<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2232-field_21_2\" name=\"wpforms[fields][21][]\" value=\"Recommend by another doctor\/health professional\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2232-field_21_2\">Recommend by another doctor\/health professional<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-2232-field_21_3\" name=\"wpforms[fields][21][]\" value=\"Just walking past\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2232-field_21_3\">Just walking past<\/label><\/li><\/ul><\/div><div id=\"wpforms-2232-field_25-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-2232-field_25\">Recommended by (if applicable)<\/label><input type=\"text\" id=\"wpforms-2232-field_25\" class=\"wpforms-field-medium\" name=\"wpforms[fields][25]\" ><\/div><div id=\"wpforms-2232-field_2-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-2232-field_2\">Comment or Message<\/label><textarea id=\"wpforms-2232-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" ><\/textarea><\/div><div id=\"wpforms-2232-field_26-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-2232-field_26\">Please ring the practice to make an appointment by calling 02 98293033<\/label><input type=\"text\" id=\"wpforms-2232-field_26\" class=\"wpforms-field-small\" name=\"wpforms[fields][26]\" ><\/div><div id=\"wpforms-2232-field_29-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"29\"><label class=\"wpforms-field-label\">By submitting this form and when you are a regular patient of this practice, you agree to receive clinically relevant recalls and\/or reminders via text or email. <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-2232-field_29\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2232-field_29_1\" name=\"wpforms[fields][29][]\" value=\"Agree\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2232-field_29_1\">Agree<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2232-field_29_2\" name=\"wpforms[fields][29][]\" value=\"Don&#039;t agree\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2232-field_29_2\">Don't agree<\/label><\/li><\/ul><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"2232\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/khoo.com.au\/index.php\/wp-json\/wp\/v2\/pages\/2170\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-2232\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/khoo.com.au\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\n","protected":false},"excerpt":{"rendered":"<p><span class=\"more-link\"><a href=\"https:\/\/khoo.com.au\/index.php\/patient-questionnaire\/\">Continue Reading<\/a><\/span><\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["entry","author-chee1404","post-2170","page","type-page","status-publish"],"_links":{"self":[{"href":"https:\/\/khoo.com.au\/index.php\/wp-json\/wp\/v2\/pages\/2170","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/khoo.com.au\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/khoo.com.au\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/khoo.com.au\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/khoo.com.au\/index.php\/wp-json\/wp\/v2\/comments?post=2170"}],"version-history":[{"count":3,"href":"https:\/\/khoo.com.au\/index.php\/wp-json\/wp\/v2\/pages\/2170\/revisions"}],"predecessor-version":[{"id":2235,"href":"https:\/\/khoo.com.au\/index.php\/wp-json\/wp\/v2\/pages\/2170\/revisions\/2235"}],"wp:attachment":[{"href":"https:\/\/khoo.com.au\/index.php\/wp-json\/wp\/v2\/media?parent=2170"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}