Referral

Please attach referral if you have it. (Camera/Upload function available)

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Usual GP

Practice Name

Patient Registration Sheet

Personal Details

First Name *

Surname *

Preferred name (if different from First Name)

Date of Birth *

Residential Address *

Postal Address

Email Address *

Mobile Phone *

Work Phone

Home Phone

Occupation *

Next of Kin *

Relationship *

Next of Kin Mobile Number *

Are you

AboriginalTorres Strait IslanderN/A

Medicare + Private Health Insurance

Medicare Number *

Reference Number *

Expiry Date *

Do you have Private Health Cover *

YesNo

Name of Health Fund *

Membership Number *

Do you have 'Gold' level cover? *

YesNo

Have you had 'Gold' Cover for more than 12 months? *

YesNo

Medical Questionnaire

Height *

Weight *

BMI

Diabetes *

YesNo

Do you take any of these Diabetes Medications? *

Dapagliflozin (FORXIGA) Empagliflozin (JARDIANCE)Combination with Metformin (XIGDUO, JARDIAMET)None of these meds

If 'YES' to any of these medications, please cease 3 days prior to surgery.

High Blood Pressure (even if treated) *

YesNo

Heart Attacks, Ischemic Heart Disease, Heart Arrhythmia, Palpitations, AF, Murmurs, Valve Problems or Stents *

YesNo

Please give more information *

Cardiologist Name *

Peripheral Vascular Disease *

YesNo

Asthma *

YesNoSeasonalWhen I was younger

Obstructive Sleep Apnoea (OSA) *

YesYes with CPAPNo

Have you had a sleep study? *

YesNo

When and where was it performed? *

What is your level of fitness? *

Run for 5 minutes or moreWalk up 2 flights of stairsCannot walk 100m without stopping to rest

Have you ever had a gastroscopy? *

YesNo

Have you ever had a colonoscopy? *

YesNo

What was the name of the doctor that performed your gastroscopy and when did it occur?

What was the name of the doctor that performed your colonoscopy and when did it occur?

Surgical History

Please list operations you've had in the past *Type 'None' if you've not had any operations

Any problems with Anaesthetic? *Write 'None' if you've never had issues with anaesthetics.

Any family problems with Anaesthesia? *Write 'None' if no history exists

Teeth: Do you have any dentures, caps, crowns, bridges or implants?

YesNo

Please draw on the picture where the dental work has been performed. *

Clear drawing

Please describe what's been marked above.

Blood Thinners

Do you take any of the following blood thinners?If 'YES' to any of these medications, please contact the office for instructions on when to cease before surgery.

Please list any other medications you are taking *Write 'None' if you're not taking any medications

Allergies

Please list any allergies

Smoking Status + Alcohol Consumption

Are you a current smoker? *

YesNoEx-smoker

How many years have you smoked? *

How many cigarettes do you smoke a day? *

What year did you quit smoking? *

Do you drink alcohol? *

YesNo

How much alcohol do you drink? *

Less than 2 drinks per week2-10 drinks per weekMore than 10 drinks per week

Do you use recreational drugs? *

NeverMarijuana OnlyOther

Any further information

Is there any further information you'd like to tell us?

Any documentation/results/investigations or photos you'd like to attach? (Camera/Upload function available)

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Patient Privacy Statement

Please read this statement carefully.

Due to the Privacy Act 1988, we require your consent to collect and hold personal information and imaging. You are entitled to request access to the information we hold and collect about you. Each request will be assessed.

The information and imaging we collect may be used for clinical, administrative, research and education (de-identified), and audit purposes.

Our primary purpose in collecting this information is to provide quality health care. We require you to provide us with your details and a full medical history so that we may properly assess, diagnose, treat and be proactive in your healthcare needs.

This means that we will use the information you provide in the following ways:

Clinical purposes.
Education, training or research purposes.
Administrative purposes in running a specialist medical practice: including pre-operative and post-operative calls using phone numbers and names you provide us, as well as hospital interaction for booking surgical services.
Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
Disclosure to others involved in your medical care, including treating doctors, anaesthetists, specialists and hospital booking staff outside this practice.
Emergencies when we are required to contact your next of kin.

Important

I have read the information above and understand why my information must be collected.
I also know this practice has a privacy policy on handling patient information.
I understand that I am not obliged to provide any information requested but failure to do so might compromise the quality of healthcare and treatment provided to me.
I am aware of my right to access the information collected about me, except in circumstances where access might legitimately be withheld.
I understand I will have the circumstances above explained to me.
I understand that if my information is to be used for any other purpose than that set out above, my further consent will be obtained.
I consent to handling my information by this practice for the purposes set out above.

Date

Signature *

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