All new patients are required to complete the following form. Alternatively, download this form as a PDF Name* Last Name* Occupation* Date of Birth* MM slash DD slash YYYY Email* Mobile* Other Phone Number* AddressStateSTATEAUSTRALIAN CAPITAL TERRITORYNEW SOUTH WALESVICTORIAQUEENSLANDSOUTH AUSTRALIAWESTERN AUSTRALIATASMANIANORTHERN TERRITORYSuburb Postcode Emergency Contact Person Relationship* Mobile* Medicare Card Number* Expiry* Your reference number on card Private Health Insurance*PRIVATE HEALTH INSURANCE *YesNoFund Name Member Number HCC/Pension No Expiry Type DVA No ColourCOLOURGoldWhiteReferring Doctor Phone Is this doctor a GP & Specialist*IS THIS DOCTOR A GP & SPECIALIST *GPSpecialistIs this your regular GP?*IS THIS YOUR REGULAR GP? *YesNoPHYSIOTHERAPIST'S DETAILSPhysiotherapist's Name Physiotherapist's Phone Physiotherapist's AddressStateSTATEAustralian Capital TerritoryNew South WalesVictoriaQueenslandSouth AustraliaWestern AustraliaTasmaniaNorthern TerritorySuburb Postcode Physiotherapist's Email Worker’s Compensation/Third Party?*WORKER'S COMPENSATION/THIRD PARTY? *YesNoWORKER’S COMPENSATON / 3RD PARTY DETAILSDate of Injury Claim Number Employer/Company Name Contact Surname Given Name Employer/Company Address Post Code Insurance Company Insurer Address Contact/Case Manager DetailsYesNoSurname 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 HISTORYArthritis?Osteoarthritis?Osteoarthritis?YesNoRheumatoid Arthritis?Rheumatoid Arthritis?YesNoEpilepsy?If yes, do you take medication?If yes, do you take medication?YesNoLiver Disease?Hepatitis B?Hepatitis B?YesNoHepatitis C?Hepatitis C?YesNoStroke(s)?Stroke(s)? YesNoPast Blood Transfusion?Past Blood Transfusion?YesNoHIV / AIDS?HIV / AIDS? YesNoKidney Conditions?Kidney Conditions? YesNoGastric Problems?Gastric Problems? YesNoIndigestion / Reflux?Indigestion / Reflux?YesNoStomach Ulcers?Stomach Ulcers?YesNoVenous Conditions?Venous Conditions? YesNoDVT (Thrombosis)?DVT (Thrombosis)?YesNoVaricose Veins?Varicose Veins?YesNoThyroid ConditionsHypo-active?Hypo-active?YesNoCardiac ProblemsHeart Attack?Heart Attack?YesNoHigh Blood Pressure?High Blood Pressure?YesNoLow Blood Pressure?Low Blood Pressure?YesNoDiabetes?Diabetes? YesNoIf yes, how is it controlled?If yes, how is it controlled?TabletsInsulinDietLung ConditionsAsthma?Asthma?YesNoEmphysema?Emphysema?YesNoSleep Apnoea?Sleep Apnoea?YesNoPulmonary Embolus?Pulmonary Embolus?YesNoAre you a Smoker?Are you a Smoker? YesNeverQuitCancer?Breast?Breast?YesNoMastectomy?Mastectomy?YesNoShoulder Region?Shoulder Region?YesNoOtherTHE 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 doLeft Shoulder - Put on a coatLeft Shoulder - Put on a coat0123Right Shoulder - Put on a coatRight Shoulder - Put on a coat0123Left Shoulder - Wash you back or do up your braLeft Shoulder - Wash you back or do up your bra0123Right Shoulder - Wash you back or do up your braRight Shoulder - Wash you back or do up your bra0123Left Shoulder - Manage toiletingLeft Shoulder - Manage toileting 0123Right Shoulder - Manage toiletingRight Shoulder - Manage toileting 0123Left Shoulder - Comb hair (if bald, do the action)Left Shoulder - Comb hair (if bald, do the action)0123Right Shoulder - Comb hair (if bald, do the action)Right Shoulder - Comb hair (if bald, do the action)0123Left Shoulder - Reach a high shelfLeft Shoulder - Reach a high shelf 0123Right Shoulder - Reach a high shelfRight Shoulder - Reach a high shelf 0123Left Shoulder - Lift 5kgs or 10 lbs above the shoulderLeft Shoulder - Lift 5kgs or 10 lbs above the shoulder0123Right Shoulder - Lift 5kgs or 10 lbs above the shoulderRight Shoulder - Lift 5kgs or 10 lbs above the shoulder0123Left Shoulder - Throw a ball overhandLeft Shoulder - Throw a ball overhand0123Right Shoulder - Throw a ball overhandRight Shoulder - Throw a ball overhand0123Left Shoulder - Do your usual work or activitiesLeft Shoulder - Do your usual work or activities 0123Right Shoulder - Do your usual work or activitiesRight Shoulder - Do your usual work or activities 0123Left Shoulder - Do your usual sport or leisure activityLeft Shoulder - Do your usual sport or leisure activity0123Right Shoulder - Do your usual sport or leisure activityRight Shoulder - Do your usual sport or leisure activity0123Are you having pain in your shoulder?Are you having pain in your shoulder?YesNoDo you have pain in your shoulder at night?Do you have pain in your shoulder at night? YesNoDo you take pain medication (Eg, Panadol, Nurofen, Aspirin etc.)?Do you take pain medication (Eg, Panadol, Nurofen, Aspirin etc.)? YesNoDo you take narcotic medication (Eg, Panadeine, Nurofen Plus or stronger)?Do you take narcotic medication (Eg, Panadeine, Nurofen Plus or stronger)?YesNoHow many tablets would you take each day (on average) just for your shoulder?How many tablets would you take each day (on average) just for your shoulder?YesNoDoes your shoulder feel unstable (i.e. as if it is going to dislocate)?Does your shoulder feel unstable (i.e. as if it is going to dislocate)? YesNoIf 0 = not at all and 10 = unstable, how unstable does your shoulder feel today?If 0 = not at all and 10 = unstable, how unstable does your shoulder feel today?012345678910CONSENT TO COLLECT PATIENT INFORMATIONThis 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?*Do you agree to the above?YesNoNameThis field is for validation purposes and should be left unchanged.
