NEW PATIENT REGISTRATION
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- Christopher Bradley
- 8 years ago
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1 Title Mr / Mrs / Ms / Miss / Master / Dr Surname Given Names Address Postcode. Date of Birth. Age Occupation Telephone H.. M. W.. Next of Kin:. Tel:.. Referring Dr. Address.. Private Insurance YES / NO Fund:... Membership No. Longer than 12 months? Yes / No Medicare Number.. Veterans Affairs YES / NO Gold / Blue / White No:.. Work cover / Third party / Public liability (please circle one) YES / NO Has liability been accepted for this injury? YES / NO Date of injury: Employer. Insurance Co. Claim No:. Contact person: Address Tel:.. Fax:
2 Your main problem! Highlight on the pictures where your problem is Briefly describe your problem. Indicate current level of pain on the following scale (circle): No Pain Intolerable Pain
3 General health information. Please list the medications you are taking: Name: Dose: Frequency: Do you take blood thinning medications? YES / NO ( eg: aspirin, warfarin, clopid, NSAIDs) Allergies? YES / NO List:... Have you ever had surgery on your back or neck before? YES / NO Have you ever had surgery on your head or brain before? YES / NO List any previous back or head surgery with dates and surgeon: Operation: Date: Surgeon:
4 Please indicate (circle) if you suffer any of the following medical problems: High blood pressure Heart Attack/s Angina Diabetes Type 1 (juvenile) Diabetes Type 2 (mature) Lung problems Heart surgery Heart stent Strokes DVT (blood clot in legs) Kidney problems Liver disease HIV Hepatitis B or C Long standing infections Cancer of any type Radiotherapy Chemotherapy Depression Migraine Siezures Gastric ulcers Reflux Constipation Do you smoke? YES / NO How much per day: Do you drink alcohol? YES / NO How much per day: Do you take any drugs/stimulants? YES / NO Are you currently receiving treatments by any of the following: Physiotherapist Chiropractor Osteopath Acupuncture Herbalist Massage therapy Hydrotherapy Traction Psychologist
5 Is there any other information about yourself that you would like us to know? List any doctors you are seeing with address and contact details: Are there any other health care providers (say, physio or chiro) that you would like correspondence to be sent to? What are the main questions you would like answered today (eg: why am I in pain?, what are my options for treatment?, will this get better by itself?, what are the risks of surgery?, should I see anyone else about this problem?, )
6 SF-8 Health Survey This survey asks for your views about your health. Please circle your response. 1. Overall, how would you rate your health during the past 4 weeks? Excellent Very good Good Fair Poor Very poor 2. During the past 4 weeks, how much did physical health problems limit your usual physical activities (such as walking or climbing stairs)? Not at all Very little Somewhat Quite a lot Could not do physical activities 3. During the past 4 weeks, how much difficulty did you have doing your daily work, both at home and away from home, because of your physical health? None at all A little bit Some Quite a lot Could not do daily work 4. How much bodily pain have you had during the past 4 weeks? None Very mild Mild Moderate Severe Very Severe 5. During the past 4 weeks, how much energy did you have? Very much Quite a lot Some A little None 6. During the past 4 weeks, how much did your physical health or emotional problems limit your usual social activities with family or friends? Not at all Very little Somewhat Quite a lot Could not do social activities 7. During the past 4 weeks, how much have you been bothered by emotional problems (such as feeling anxious, depressed or irritable)? Not at all Slightly Moderately Quite a lot Extremely 8. During the past 4 weeks, how much did personal or emotional problems keep you from doing your usual work, school or other daily activities? Not at all Very little Somewhat Quite a lot Could not do daily activities
7 Please sign below: o I have filled this form out honestly and to the best of my knowledge. o I understand that my details will be kept confidential as per the Privacy Act. o I agree to pay the quoted consultation fees for this service. o I will pursue a second opinion if I am unhappy with the advice and management options that will be discussed / presented to me. o I understand two people with the same disorder may be managed differently because of differences in severity of symptoms and other medical factors that are unique to each person. Signed: Date:..
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