PATIENT REGISTRATION

Title *

Given Names *

Surname *

Address *

Suburb *

State *

Postcode *

Date of Birth *

Age in Years

Occupation *

Home Phone

Work Phone

Mobile

Please enter at least one phone number

Email Address *

Emergency Contact *

Relationship *

Phone *

Medicare Number *

Position on card *

Expiry *

Private Health Fund *

Membership Number *

Health CarePensionDVA

Card Number

Expiry

The following parent Medicare fields are required for benefits to be paid to this adult.

Parent Name (if child 13 or under)

Parent DOB

Parent Medicare

Position on card

Expiry

CORRESPONDENCE DETAILS

General Practitioner *

GP Phone *

GP Address *

GP Suburb & Postcode *

Is this a Worker's Compensation or CTP case? *

Worker's CompensationCTPNo

Type of Injury *

Date of Injury *

Insurance Company *

Claim Number *

Case Manager *

Case Manager Phone *

Employer *

Employer Phone *

Employer Address *

Employer Suburb & Postcode *

Physio/Chiro

PhysiotherapistChiropractorOther

Physio/Chiro Name

Physio/Chiro Phone

Physio/Chiro Address

Physio/Chiro Suburb & Postcode

YOUR SYMPTOMS

Affected Area *

ShoulderElbowN/A

Affected Side *

RightLeftBoth

Hand Dominance *

RightLeftAmbidextrous

When did the symptoms start? *

Were they from an injury?

YesNoUnsure

If so, what type of injury? *

Do you have any stiffness? *

YesNo

Do you have any weakness? *

YesNo

Have you ever dislocated your shoulder/elbow? *

YesNo

How many times? *

Have you had physiotherapy for this condition? *

YesNo

Duration? *

Have you had injections for this condition? *

YesNo

Number and date of last injection? *

Have you had surgery for this condition? *

YesNo

Please list *

Do you take pain medications? *

YesNo

Please list *

Do you take any herbal medications? *

YesNo

Please list *

Are you taking any blood thinners? *

YesNo

Please list *

Other treatment *

YesNo

Please describe *

Are you retired? *

YesSemi-retiredNo

What is (or was) your occupation? *

Sports you play

CONSENT TO COLLECT PATIENT INFORMATION

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 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.
Research and teaching purposes (all information, medical imaging and clinical photography used will be de-identified)

Signature *

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Date