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Patient Form

Name*
Last Name*
Occupation*
Date of Birth*
Email*
Mobile*
Other Phone Number*
Address
State
Suburb
Postcode
Emergency Contact Person
Relationship*
Mobile*
Medicare Card Number*
Expiry*
Your reference number on card
Private Health Insurance*
Fund Name
Member Number
HCC/Pension No
Expiry
Type
DVA No
Colour
Referring Doctor
Phone
Is this doctor a GP & Specialist*
Is this your regular GP?*
PHYSIOTHERAPIST'S DETAILS
Physiotherapist's Name
Physiotherapist's Phone
Physiotherapist's Address
State
Suburb
Postcode
Physiotherapist's Email
Worker’s Compensation/Third Party?*
WORKER’S COMPENSATON / 3RD PARTY DETAILS
Date of Injury
Claim Number
Employer/Company Name
Contact Surname
Given Name
Employer/Company Address
Post Code
Insurance Company
Insurer Address
Contact/Case Manager Details
Surname
Surname
Name
Phone
Email
NOTE: The above details are true to the best of my knowledge and permission is hereby given to release medical details to my local doctor, solicitor or insurance company.
MEDICAL HISTORY
Do you wish to share your medical history now?
Arthritis?
Osteoarthritis?
Rheumatoid Arthritis?
Epilepsy?
If yes, do you take medication?
Liver Disease?
Hepatitis B?
Hepatitis C?
Stroke(s)?
Past Blood Transfusion?
HIV / AIDS?
Kidney Conditions?
Gastric Problems?
Indigestion / Reflux?
Stomach Ulcers?
Venous Conditions?
DVT (Thrombosis)?
Varicose Veins?
Thyroid Conditions
Hypo-active?
Cardiac Problems
Heart Attack?
High Blood Pressure?
Low Blood Pressure?
Diabetes?
If yes, how is it controlled?
Lung Conditions
Asthma?
Emphysema?
Sleep Apnoea?
Pulmonary Embolus?
Are you a Smoker?
Cancer?
Breast?
Mastectomy?
Shoulder Region?
Other
THE AMERICAN SHOULDER & ELBOW SOCIETY RATING SCALE
Would you like to complete the American Shoulder & Elbow Society Rating Scale?
Select the number that indicates your ability to do the activity normally (i.e. not just today), complete details for both shoulders please. Note: 0 = unable to do and 3 = easy to do
Left Shoulder - Put on a coat
Right Shoulder - Put on a coat
Left Shoulder - Wash you back or do up your bra
Right Shoulder - Wash you back or do up your bra
Left Shoulder - Manage toileting
Right Shoulder - Manage toileting
Left Shoulder - Comb hair (if bald, do the action)
Right Shoulder - Comb hair (if bald, do the action)
Left Shoulder - Reach a high shelf
Right Shoulder - Reach a high shelf
Left Shoulder - Lift 5kgs or 10 lbs above the shoulder
Right Shoulder - Lift 5kgs or 10 lbs above the shoulder
Left Shoulder - Throw a ball overhand
Right Shoulder - Throw a ball overhand
Left Shoulder - Do your usual work or activities
Right Shoulder - Do your usual work or activities
Left Shoulder - Do your usual sport or leisure activity
Right Shoulder - Do your usual sport or leisure activity
Are you having pain in your shoulder?
Do you have pain in your shoulder at night?
Do you take pain medication (Eg, Panadol, Nurofen, Aspirin etc.)?
Do you take narcotic medication (Eg, Panadeine, Nurofen Plus or stronger)?
How many tablets would you take each day (on average) just for your shoulder?
Does your shoulder feel unstable (i.e. as if it is going to dislocate)?
If 0 = not at all and 10 = unstable, how unstable does your shoulder feel today?
CONSENT TO COLLECT PATIENT INFORMATION
This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. We will use the information you provide in the following ways:
- Administrative purposes in running our medical practice.
- Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice as advised by you. If you would like to see the detailed consent, please advise one of the administrative staff. Medicare partially covers the cost of your consultation. The full consultation fee is payable in on the day the consultation. The Medicare rebate can then be claimed back.
Do you agree to the above?*
Comments
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