DR DAVID DUCKWORTH

PATIENT REGISTRATION

Title *

First Name *

Surname *

Middle Name

Street Address *

Suburb *

State *

Postcode *

Date of Birth *

Home Phone

Mobile phone

Please add at least one phone number

Age in years

Email Address *

Occupation *

Next of Kin Name *

Relationship *

Contact Number *

Entitlements

Medicare Number *

Medicare Ref *Number to the left of name

Expiry *mm / yyyy

For claiming purposes, if the patient is under 12, parent's details are required.

Parent's Name *

Medicare Ref *Number to left of name

Parent DOB *

Expiry *mm / yyyy

DVA Number

Private Health Fund Details

Insurance *

Private Health FundNo Insurance (Self-funded)

Health Fund Name *

Membership Number *

General Practitioner

These details allow us to keep your family doctor informed of your treatment.

I do not have a family doctor / General Practitioner

Name *

Phone *

Practice Address *

Physiotherapist

These details allow us to keep your physiotherapist informed of your treatment.

Name

Phone

Practice Address

Are you making a claim for compensation?

Claim Number

Date of Injury

Insurance Company Name

Address

Declaration

I have read the Privacy Amendment Act provided and give permission for correspondence to be sent to my referring Doctor and General Practitioner and Insurance Company where appropriate.

I undertake to pay all fees owing to Dr Duckworth, including in the event that liability is denied or any outstanding accounts that have not been paid in full by my insurer.

I also understand that any outstanding monies requiring debt recovery will incur Debt Recovery fees and I will also be responsible for any legal costs incurred.

I agree *

Signature *

Draw signature|Type signatureClear

Shoulder / Elbow Questionnaire

Hand Dominance *

RightLeftAmbidextrous

On what date did your problem begin? *

If you have had an injury, please describe it in detail

Pain - Duration *

ConstantIntermittentOn certain movements

Pain - Interferes with sleep *

YesNo

Do you take pain relief? *

YesNo

Tablets / day *

What treatments have you had so far?

Physiotherapy

Sessions

Benefit

WorseNoneBetter

Anti-inflammatories

Sessions

Benefit

WorseNoneBetter

Steroid (cortisone) injections

Sessions

Benefit

WorseNoneBetter

Surgery

Sessions

Benefit

WorseNoneBetter

Other

Please describe

Medical History

Treated with

DietTabletsInsulin

Select all that apply

List any operations you have had in the past

List any medications you are currently taking

Did you suffer any major complications after previous operations? If so, what?

Do you have any allergies? What happens? *If no known allergies, please write NONE

Do you smoke? *

YesNo, but used toNever smoked

How many per day? *

When did you quit? *

Do you drink any alcohol? *

YesNo

How many drinks / day? *

GP referral and other reports

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For enquiries, please phone (02) 9806 3333

WAHROONGA
Suite 601B, The San Clinic
Sydney Adventist Hospital
185 Fox Valley Road
Wahroonga NSW 2076

BELLA VISTA
G18 - Ground floor
Norwest Private Hospital
11 Norbik Drive
Bella Vista NSW 2153

www.drdavidduckworth.com.au