Patient Information Form Title(Required) Mr Mrs Ms Miss Master Dr Other Gender(Required)Given Name(s)(Required)Surname(Required)Known AsDate of Birth(Required)Age(Required)Phone (H)Phone (W)Phone (M)Email(Required)Address(Required) Street Address Address Line 2 Post Code OccupationEmergency Contact(Required)Relationship(M)(Required)General Practitioner(Required)Doctor's Address(Required)Referring Doctor (if different)PhysiotherapistPhysiotherapist's AddressINSURANCEPrivate Health Fund(Required)Member No.(Required)Medicare No.(Required)Position On Card(Required)Expiry Date(Required)If Patient is Under 15 Years Old (Guardian details)Guardian: NameDate of BirthMedicare No.Worker's Compensation(Required) Yes No Date of OnsetClaim NumberEmployerInsurerCase ManagerContactRehabilitation CoordinatorContactADF(Required) Yes No PMKeysRankDANVeterans' Affairs No.ExpiryCard White Gold Medical HistoryName(Required)Height (cm)(Required)Weight (kg)(Required)Date of Injury / When did the symptoms first occurWhat sports or physical activities do you participate inDo you suffer from any of the following medical illnesses?illnesses column 1 High Blood Pressure Angina / Chest Pain Circulation Problems Asthma / Airways Disease Thyroid Disease Stomach Ulcers / Reflux Mental Health Issues Blood Clots Leg / Lung HIV / AIDS illnesses column 2 Heart Disease Heart Murmur Bleeding Disorders Bronchitis Renal/Kidney Problems Liver Disease / Jaundice Rheumatic Fever Family History of Clots Contact with HIV/AIDS or Hepatitis B illnesses column 3 Heart Attack Stroke Leg Cramps Diabetes Epilepsy Hepatitis B or C Sleep Apnoea CancerOtherHave you ever had a blood tranfusion?(Required) Yes No If yes, when?Any problems/reactionsDo you take any of the following?Medications 1 Aspirin Hormone Replacement Anti-arthritic Medication Plavix Warfrarin Xarelto Medications 2 Oral Contraceptive Pill/Implant Anti-coagulants Xarelto Heparin Eliquis Iscover Clexane Current Medications including non-prescriptionCurrent AllergiesPast OperationsHave you previously had any anaesthetic problems?(Required) Yes No Have you been told you have a difficult airway?(Required) Yes No Do you smoke/vape?(Required) Yes No If yes, how regularly?Do you drink alcohol?(Required) Yes No If yes, drinks per weekPlease provide any additional information you think is important for us to knowYour consultation is in the private rooms of a private clinic I understand that full payment for consultation and consumables is required at the time of the consultation. If difficulties with payment are anticipated, please discuss with Dr Gordiev’s staff prior to the appointment. It is not the policy of this practice to bulk bill for services rendered. In cases where unpaid accounts are referred to a Collection Agency, all legal costs and omission will be added to the amount due. Workers’ Compensation/Third Party claims will need to be settled at the time of consultation if prior approval I not received in writing from the insurer. I give consent for medical information concerning myself, or my child, to be released to my insurer, employer, solicitor, my referring GP, and other health professionals involved in my care. I give consent to the above information and any other relevant medical information being scanned and stored in my electronic patient file. Name(Required)
