New Patient Details
Title
*
First Name
*
Middle Name
Last Name
*
Patient Gender
*
Date of Birth
*
Address Line 1
*
Address Line 2
Suburb
*
State
*
Postcode
*
Email Address
Mobile Phone Number
*
Home Phone Number
Do you have a Medicare Card?
*
Yes
No
Medicare Card Number
Medicare Reference Number (the number before your name)
Expiry Date
Do you have private health insurance?
*
Yes
No
Health fund name
Health fund number
Do you have hospital cover through your health fund?
Yes
No
Unsure
Health fund reference number (2 digits next to your name)
Do you have a DVA Gold Card?
*
Yes
No
Veterans File Number
Emergency Contact Details
Full Name of Emergency Contact
*
Phone Number of Emergency Contact
*
Patient's Relationship to Emergency Contact
*
Name of Patient's GP
*
GP Practice Name
*
Name of Patient's Dentist
*
Dentist Practice Name
*
Medical History
Do you have a history of any of the following conditions?
High blood pressure
Heart failure
Valvular heart disease
Rheumatic heart disease
Other heart condition
Asthma
COPD
Tuberculosis
Other lung condition
Anaemia
Bleeding or clotting disorders
Diabetes
Kidney condition
Arthritis
Osteoporosis
Other bone condition
Epilepsy
Previous stroke/TIA
Depression/Anxiety
Other mental health condition
Hepatitis A, B or C
HIV
Cancer
Other
Do you take any regular prescribed medications?
*
Yes
No
If yes, please advise the details of the medication name, dose and frequency of each below:
Do you take any supplements, vitamins, herbal medications or over the counter medications?
*
Yes
No
If yes, please advise the supplement/vitamin name, dose and frequency for each below:
Are you allergic to any medications?
Yes
No
If yes, please advise the medication and the reaction below:
Have you ever had a reaction to local or general anaesthetic?
*
Yes
No
If yes, please describe your reaction below:
Have you had any previous joint replacement surgery e.g. shoulder, hip, knee?
*
Yes
No
If yes, please advise which joint was replaced and when surgery was performed
Have you had any other previous surgery?
*
Yes
No
If yes, please advise the type of surgery and when surgery was performed
Do you bleed excessively after accidentally cutting yourself or after surgery?
*
Yes
No
Do you smoke?
*
Yes
No
Do you drink alcohol?
*
Yes
No
Any other information which you feel is relevant to your medical history?
Please upload your referral letter or any diagnostics you may have available for Dr Chellappah.
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