Dr Geoffrey Smith
Patient Registration Form
Patient Details
First name
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Last name
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Date of Birth
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Sex
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Male
Female
Other
Email address
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Mobile Phone
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Street Address
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Suburb
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Post Code
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Is postal address the same as residential address?
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Yes
No
Postal address (number, street, suburb, postcode)
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Next of kin (name)
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Next of kin relationship to patient?
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Next of kin contact number
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Next of kin email
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Patient Registration Form
Medicare Details
Is the patient eligible for Medicare / DVA?
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Yes
No
Is the patient 18 years old or older?
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Yes
No
Patient Medicare/DVA Card Number
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Patient Medicare/DVA Card Line Number (Ref)
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Patient Medicare / DVA Card Expiry (MM/YYYY)
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Parent Medicare/DVA Card Number
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Parent Medicare/DVA Card Line Number (Ref)
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Parent Medicare/DVA Card Expiry
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Other Medical Practitioners
GP Name:
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GP Clinic
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Do you see a physiotherapist?
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Yes
No
Physiotherapist details
Insurance Details
Do you have private health insurance (healthfund or travel insurance)?
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Yes
No
Health or travel insurance company name
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Health or travel insurance company policy number
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Do you have an aged pension card?
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Yes
No
Aged pension card number
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Is this a workers compensation claim?
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Yes
No
Workers compensation claim number
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Insurance company name
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Is this a third party claim?
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Yes
No
Third Party Insurance Claim Number
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Third Party Insurance company name
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About the condition / injury
What is your handedness?
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Right
Left
Ambidextrous
Please select all the areas affected
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Right Shoulder Area
Left Shoulder Area
Right Elbow Region (including forearm)
Left Elbow Region (including forearm)
Other (please provide details)
Other area/s affected
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Was there an injury?
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Yes
No
Date of injury
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How did the injury happen?
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What treatments have you tried so far?
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Physiotherapy
Steroid Injection
PRP Injection
Splint
Acupuncture
Chiro
Painkilling tablets
Anti-inflammatories
Other (please provide details)
None
Details of other treatment/s
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Have you had any scans/imaging done (please select all that apply)
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Ultrasound
Radiographs (x-rays)
CT scan
MRI
Other (please provide details)
None
Where did you have the ultrasound done?
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When did you have the ultrasound done?
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Where did you have the radiographs (x-rays) done?
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When did you have the radiographs (x-rays) done?
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Where did you have the CT done?
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When did you have the CT done?
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Where did you have the MRI done?
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When did you have the MRI done?
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Other (please provide details)
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Past Medical History
Please select any health issues that you have
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None
Hypercholesterolaemia / Dyslipidaemia
Hypertension
Angina
NSTEMI / MI (heart attack)
Stent (coronary artery)
CABG
Heart valve problems
Heart valve surgery (including TAVI)
Heart rhythm abnormality
Previous ECHO scan
Asthma / COPD
Brochiectectasis
Obstructive sleep apnoea
TIA / Stroke
Epilepsy
Parkinson’s disease
Dementia
DVT / PE
Anaemia
Lymphoma / Leukaemia
Bleeding disorder
Reflux / GORD
Liver disease
Kidney Disease
Rheumatoid arthritis
Autoimmune disorder
Gout / pseudogout
Osteoporosis
Diabetes / impaired glucose tolerance
Thyroid disorder (hypo or hyperthyroidism)
Skin condition
Cancer
Other
If 'other' health issue selected please provide details
Please select any medications that you take?
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None
Aspirin
Non steroidal anti-inflammatories
Clopidogrel (Plaxix)
Apixaban (Eliquis)
Rivaroxaban (Xarelto)
Dagibatran (Pradaxa)
Warfarin
Metformin
SGLT-2 inhibitors (eg Jardaince)
Insulin
Semaglutides (Ozempic, Wegovy)
Other diabetic medication
ACE inhibitors
Lipid lowering treatment
HRT
OCP
Immunosuppressants (methotrexate, azathioprine, tacrolimus, cyclosporin, DMARD's)
Prednisolone
Herbal Medications or Supplements
Other
If 'other' medication selected please provide details
Do you have any allergies to medications?
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None
Chlorhexidine
Iodine
Dressings
Antibiotics
Analgesics (painkillers)
Aspirin or anti-inflammatories
Latex
Other
Please list allergies/reactions to medications
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Do you have any food or environmental allergies?
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Yes
No
Please list allergies / reactions to food or environmental allergens
Further information
What is your occupation?
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What are your sports / hobbies?
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Privacy policy
This practice is, as a health provider in the private sector, bound by the National Privacy Principles and the Health Records and Information Privacy Act 2002 (NSW). These Principles set the standards by which personal information is collected from patients. A copy of these Principles is available from the Department of Health or the Australian Medical Association.As part of your treatment, it is usual to write to your referring Doctor, the Physiotherapist involved in your care, and any other Specialists to whom you are referred, including x-rays MRI’s etc. In the case of compensation matters it may be necessary to write to the Insurers, Solicitor, and Employer and/or rehabilitation provider. As outlined in the above mentioned guidelines, only the necessary information will be released. For quality assurance and research, information may be extracted from you record and held on a specific secure database on occasions. It may be necessary for us to contact you for ongoing assessment. I HEREBY AUTHORISE THE RELEASE OF MY MEDICAL HISTORY TO MY FAMILY DOCTOR/INSURANCE COMPANY/SOLICITOR WHERE APPLICABLE) AND TO TAKE RESPONSIBILITY FOR THE PAYMENT OF ALL ACCOUNTS PRIVATE OR INSURANCE.
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Yes
No
Do you consent for the use of de-identified radiographic or intra-operative images to be used for teaching, medical education or research purposes including computer modelling?
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Yes
No
Do you consent to complete 'patient reported outcome measures' (PROMS), which are sent to you electronically so that your recovery after surgery (if it is required) can be monitored? (PROMS data, deidentified diagnostic and treatment details will be stored on a secured REDCAP database)
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Yes
No
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