Patient Form | Focus Shoulder Specialists

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Patient Information Sheet

Title

Name*

First Last

Date of Birth*

Day

Month

Year

Occupation*

Address

Postcode

Phone

Mobile*

Email*

Emergency Contact

Relationship

Mobile

Please provide us with your height and weight. This allows us to select the most appropriate hospital for your care in the event of surgery. If you do not provide this to us, you may be weighed at your consult.

Height*

in CM

Weight*

in Kg

Medicare No.*

Expiry Month*

Expiry Year*

Your reference number*

Private health insurance:*

Yes

Fund Name

Member No

HCC/Pension No

Expires

Day

Month

Year

Type

Gold

White

DVA No

Referring doctor

Phone

Is this a GP or a Specialist?

Specialist

If this is not your regular General Practitioner, please give detail

Phone

Address

Postcode

Physiotherapist

Phone

Address

How did you hear about us?

Doctor or specialist

Emergency staff

Another patient

Family or friend

Google search

Instagram

Facebook

Physiotherapist

Workcover manager

Signage

How did your injury occur?

Worker's Compensation / 3rd Party Details

Skip to the next section if not applicable.

Date of Injury

Day

Month

Year

Claim Number

Employer/Company Name

Contact Name

First Last

Phone

Employer/Company Address

Postcode

Insurance Company

Insurer Address

Contact/Case manager details

First Last

Phone

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.

Consent

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.

Consent

Medical Allergy and Surgical History

Do you regularly take

Warfarin

Plavix

Aspirin

or other blood thinners

Details

Do you regularly take Herbal medications

Yes

If so, which ones

Do you regularly take Pain Medications

Yes

If so, specify type, quantity and frequency?

Other current medications

Do you drink alcohol?

Yes

If yes, how many days per week do you drink?

How many drinks per day?

Do you have any allergies to DRUGS?

Yes

None known

If yes, which DRUGS?

What allergic reaction to drugs do you have?

Rash

Shortness of Breath

Swelling

Anaphylaxis

Other (provide details)

What else (apart from drugs) are you allergic to (Eg: latex, food, dust mites, cats, dogs)?

Have you had previous orthopaedic surgery? (NB: not just on the shoulder or elbow – any type)

Yes

Have you ever had complications after surgery?

Yes

What type of surgery and when?

If yes, what were the complications

Medical History

Arthritis

Osteoarthritis

Yes

Rheumatoid Arthritis?

Yes

Epilepsy

Yes

If yes, do you take medication?

Yes

Liver Disease

Hepatitis B?

Yes

Hepatitis C?

Yes

Stroke(s)?

Yes

Past Blood Transfusion?

Yes

HIV/AIDS?

Yes

Kidney Conditions?

Yes

Gastric Problems?

Yes

Indigestion / Reflux?

Yes

Stomach Ulcers?

Yes

Venous Conditions?

Yes

DVT (Thrombosis)?

Yes

Varicose Veins?

Yes

Thyroid conditions

Hypo-active?

Yes

Hyper-active?

Yes

Cardiac Problems

High Blood Pressure

Yes

Heart Attack

Yes

Low Blood Pressure

Yes

Other?

Diabetes?

Yes

If yes, how is it controlled?

Tablets

Insulin

Diet

Lung Conditions

Asthma?

Yes

Emphysema?

Yes

Sleep Apnoea?

Yes

Pulmonary Embolus?

Yes

Are you a smoker?

Yes

Never

Quit

Cancer?

Breast?

Yes

Mastectomy?

Yes

Shoulder Region?

Yes

Other

Issues with Other Joints

Yes

If yes, which ones?

Shoulder/Elbows Symptoms

Which shoulder/elbow is it?

Left

Right

Both

Hand Dominance

Left

Right

Both

When did symptoms start? (approx)

Day

Month

Year

Did symptoms start:

Suddenly

Gradually

From an injury?

Yes

Unsure

If yes, when was the injury

Day

Month

Year

Injury type:

Sport

Fall

Car Accident

Bicycle Accident

Motorbike Accident

Work Accident

Repetitive Injury

Other

Do you, or have you had any shoulder/elbow:

Weakness?

Yes

Dislocations?

Yes

If yes, how many have you had?

Do you experience any shoulder stiffness?

Yes

To treat your symptoms have you had any:

Physiotherapy?

Yes

Injections?

Yes

How many Physio appointments?

How many Injections?

Previous surgeries?

Yes

If yes, when?

Type / Name?

Other Treatment?

Yes

If yes, describe briefly?

The American Shoulder & Elbow Society Rating Scale

If 0 = no pain and 10 = the worst pain, how bad is your pain today out of 10?

Put on a coat

Left

Unable

Very difficult

A bit difficult

Easy to do

Right

Unable

Very difficult

A bit difficult

Easy to do

Sleep on your side

Left

Unable

Very difficult

A bit difficult

Easy to do

Right

Unable

Very difficult

A bit difficult

Easy to do

Wash your back or do up your bra

Left

Unable

Very difficult

A bit difficult

Easy to do

Right

Unable

Very difficult

A bit difficult

Easy to do

Manage toileting

Left

Unable

Very difficult

A bit difficult

Easy to do

Right

Unable

Very difficult

A bit difficult

Easy to do

Comb hair (if bald, do the action)

Left

Unable

Very difficult

A bit difficult

Easy to do

Right

Unable

Very difficult

A bit difficult

Easy to do

Reach a high shelf

Left

Unable

Very difficult

A bit difficult

Easy to do

Right

Unable

Very difficult

A bit difficult

Easy to do

Lift 5kgs or 10lbs above the shoulder

Left

Unable

Very difficult

A bit difficult

Easy to do

Right

Unable

Very difficult

A bit difficult

Easy to do

Throw a ball overhand

Left

Unable

Very difficult

A bit difficult

Easy to do

Right

Unable

Very difficult

A bit difficult

Easy to do

Do your usual work or activities

Left

Unable

Very difficult

A bit difficult

Easy to do

Right

Unable

Very difficult

A bit difficult

Easy to do

Do your usual sport or leisure activity

Left

Unable

Very difficult

A bit difficult

Easy to do

Right

Unable

Very difficult

A bit difficult

Easy to do

Are you having pain in your shoulder/elbow?

Yes

Do you have pain in your shoulder/elbow at night?

Yes

Do you take pain medication (Eg, Panadol, Nurofen, Aspirin etc.)?

Yes

Do you take narcotic medication (Eg, Panadine, Nurofen Plus or stronger?

Yes

How many tablets would you take each day (on average) just for your shoulder?

Yes

Does your shoulder/elbow feel unstable (i.e. as if it is going to dislocate)?

Yes

If 0 = not at all and 10 = unstable, how unstable does your shoulder/elbow feel today?

Consent to collect patient information

Consent*

I agree to the practice policy.

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 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 for operating our medical practice.

Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.

X-rays, imaging, and photographs may be shared with our online community for educational purposes. We take great care to protect patient privacy and will not disclose any identifying information. If you are a patient and do not wish for your medical information to be used in this way, please inform us immediately so that we can respect your wishes. Our primary goal is to provide education and training for healthcare professionals, and we thank you for your understanding.

Please be advised of our consultation fees:

Pre-surgery consultations $280.00

Initial consultations (fracture) $330.00

Second opinion consultations $380

Post-surgery consultations $95

In order to be eligible for medicare rebates, new patients must have a referral from a GP.

Please note, the full consultation fee is payable on the day of the consultation.
Mastercard/Visa card surcharge 0.97%
Mastercard/Visa debit surcharge 0.97%
EFTPOS cheque/savings surcharge 0.27%
Amex 1.5% surcharge

The 2-week and 6-week appointments post-surgery are included in the surgical fee. Appointments after 6 weeks are considered Follow-up post-surgery appointments.

Date*

Day

Month

Year

Patient Name (Please print):*

Post Custom Field

All new patients are required to complete the following form.

Patient Information Sheet

Worker's Compensation / 3rd Party Details

Medical Allergy and Surgical History

Medical History

Arthritis

Liver Disease

Thyroid conditions

Cardiac Problems

Lung Conditions

Cancer?

Other

Shoulder/Elbows Symptoms

Do you, or have you had any shoulder/elbow:

To treat your symptoms have you had any:

The American Shoulder & Elbow Society Rating Scale

Consent to collect patient information