All new patients are required to complete the following form. Alternatively, download this form as a PDF Step 1 of 6 16% Patient Information SheetTitle Name* First Last Date of Birth* Day Month Year Occupation* Address Postcode Phone*Mobile*Email* Emergency Contact Relationship MobileMedicare No. Expiry Date Day Month Year Your reference number on card Private health insurance: Yes No Fund Name Member No HCC/Pension No Expires Day Month Year Type Gold White DVA No Referring doctor PhoneIs this a GP or a Specialist? GP Specialist If this is not your regular General Practitioner, please give detail PhoneAddress Postcode Physiotherapist PhoneAddress Email How do you hear about us? Doctor Word of mouth Signage Patient Google Worker's Compensation / 3rd Party DetailsDate of Injury Day Month Year Claim Number Employer/Company Name Contact Name First Last PhoneEmployer/Company Address Postcode Insurance Company Insurer Address Contact/Case manager details First Last PhoneEmail 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.Signed Date Day Month Year Print Name Medical Allergy and Surgical HistoryDo you regularly take Warfarin Plavix Aspirin or other blood thinners Details Do you regularly take Herbal medications Yes No If so, which ones Do you regularly take Pain Medications Yes No If so, specify type, quantity and frequency? Other current medications Do you drink alcohol? Yes No If yes, how many days per week do you drink? How many drinks per day? Do you have any allergies to DRUGS? Yes No 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 No Have you ever had complications after surgery? Yes No What type of surgery and when? If yes, what were the complications Medical HistoryArthritisOsteoarthritis Yes No Rheumatoid Arthritis? Yes No Epilepsy Yes No If yes, do you take medication? Yes No Liver DiseaseHepatitis B? Yes No Hepatitis C? Yes No Stroke(s)? Yes No Past Blood Transfusion? Yes No HIV/AIDS? Yes No Kidney Conditions? Yes No Gastric Problems? Yes No Indigestion / Reflux? Yes No Stomach Ulcers? Yes No Venous Conditions? Yes No DVT (Thrombosis)? Yes No Varicose Veins? Yes No Thyroid conditionsHypo-active? Yes No Hyper-active? Yes No Cardiac ProblemsHigh Blood Pressure Yes No Heart Attack Yes No Low Blood Pressure Yes No Other? Diabetes? Yes No If yes, how is it controlled? Tablets Insulin Diet Lung ConditionsAsthma? Yes No Emphysema? Yes No Sleep Apnoea? Yes No Pulmonary Embolus? Yes No Are you a smoker? Yes Never Quit Cancer?Breast? Yes No Mastectomy? Yes No Shoulder Region? Yes No Other Issues with Other Joints Yes No If yes, which ones? Shoulder SymptomsWhich shoulder 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 No 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:Weakness? Yes No Dislocations? Yes No If yes, how many have you had? Do you experience any shoulder stiffness? Yes No To treat your symptoms have you had any:Physiotherapy? Yes No Injections? Yes No How many Physio appointments? How many Injections? Previous surgeries? Yes No If yes, when? Type / Name? Other Treatment? Yes No If yes, describe briefly? The American Shoulder & Elbow Society Rating ScaleIf 0 = no pain and 10 = the worst pain, how bad is your pain today out of 10? Put on a coatLeft shoulder Unable Very difficult A bit difficult Easy to do Right shoulder Unable Very difficult A bit difficult Easy to do Sleep on your side Left shoulder Unable Very difficult A bit difficult Easy to do Right shoulder Unable Very difficult A bit difficult Easy to do Wash your back or do up your bra Left shoulder Unable Very difficult A bit difficult Easy to do Right shoulder Unable Very difficult A bit difficult Easy to do Manage toileting Left shoulder Unable Very difficult A bit difficult Easy to do Right shoulder Unable Very difficult A bit difficult Easy to do Comb hair (if bald, do the action) Left shoulder Unable Very difficult A bit difficult Easy to do Right shoulder Unable Very difficult A bit difficult Easy to do Reach a high shelf Left shoulder Unable Very difficult A bit difficult Easy to do Right shoulder Unable Very difficult A bit difficult Easy to do Lift 5kgs or 10lbs above the shoulder Left shoulder Unable Very difficult A bit difficult Easy to do Right shoulder Unable Very difficult A bit difficult Easy to do Throw a ball overhand Left shoulder Unable Very difficult A bit difficult Easy to do Right shoulder Unable Very difficult A bit difficult Easy to do Do your usual work or activities Left shoulder Unable Very difficult A bit difficult Easy to do Right shoulder Unable Very difficult A bit difficult Easy to do Do your usual sport or leisure activity Left shoulder Unable Very difficult A bit difficult Easy to do Right shoulder Unable Very difficult A bit difficult Easy to do Are you having pain in your shoulder? Yes No Do you have pain in your shoulder at night? Yes No Do you take pain medication (Eg, Panadol, Nurofen, Aspirin etc.)? Yes No Do you take narcotic medication (Eg, Panadine, Nurofen Plus or stronger? Yes No How many tablets would you take each day (on average) just for your shoulder? Yes No Does your shoulder feel unstable (i.e. as if it is going to dislocate)? Yes No If 0 = not at all and 10 = unstable, how unstable does your shoulder feel today? 0 1 2 3 4 5 6 7 8 9 10 Consent 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 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. 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. Phone/Telehealth Consultation agreement – due to COVID-19 restrictions Dr Dan may call you instead of a face to face consult. These appointments will be bulk billed direct to Medicare. New Consultations $250 Second Opinion consultations $330 Follow-up appointments $95 Note: The 2 week and 6 week appointments post-surgery are included in the surgical fee. Appointments after 6 weeks are considered Follow-up appointments.Signed:* Date* Day Month Year Patient Name (Please print):* NameThis field is for validation purposes and should be left unchanged.
