Dr Stuart Myers

Registration & Questionnaire


Please complete and sign this Patient Registration and Medical History form prior to attending your appointment.

When attending, bring to appointment:
  *    Medicare Card
  *    Health Insurance Details
  *    General Practitioner Referral letter
  *    3rd Party or Worker's Compensation claim approval/details if relevant
  *    All Xrays, scans and their reports
  *    Recent blood tests
  *    Interpreter if you have a language barrier

Demographics

Include Suburb
If no mobile phone insert contact person mobile number
Is this Private, Public , Workers Comp, 3rd Party, or Veterans. Please note Dr Myers no longer works in the Public Hospital.

If Patient is a Child

Age 16 years or less.
Parents Ref Number

Emergency Contact, Next of Kin

3rd Party and Worker's Compensation

Please note Dr Myers requires written approval from your workplace insurer prior to your appointment. If no prior written approval is received you will need to pay for the appointment yourself and claim back from the insurer.

Medical History

The relevance of some questions below may not be immediately apparent to you. They may however be critical in your diagnosis or management. Please take your time to fill in this form. Hand Surgery is about attention to detail.
Which hand do you use to write with or perform most activities with?
If Different eg Gymnastics
Eg Tendon rupture or fracture is an "Injury". Trigger finger or Carpal Tunnel Syndrome or "Overuse" is a "Condition"

Injury Details

If appropriate
How & Where did injury occur?

Hand Condition Details

If hand problem is not due to an injury.
eg Hand , Fingers, Wrist
eg Days, Months , Years
eg Unusual activity, Woke up with symptoms
On a scale from 0 - 10 how do you rate your pain at worst? 0 = No Pain, 10 = Worst pain you can imagine eg Chopping your leg off with a chain saw!
eg Fractured wrist as a child
eg Diabetes, Inflammatory arthritis, Psoriasis
Smokers & Ex smokers may tick several boxes as approriate
eg Penicillin,

Investigations

It is vital to bring all previous investigations with you to the appointment. Many BUT NOT ALL xrays can be accessed online by Dr Myers. If you have had Xrays at a public hospital you must ask for them to be put onto a CD. Dr Myers is unable to access xrays done in the public hospital. If they were not done at one of the Xray practices listed below Dr Myers may not be able to access the images

Terms of Service

I give my consent to Dr Myers to take photographs if required, prior to, during and after surgery for the purpose of my medical records. I give permission for these photographs to be used for teaching and educational purposes. I give permission for these photographs to be shown to other patients. I understand that I will not be identified in these photographs. Dr Myers may use some of your details for the purpose of audit/or medical research. Please indicate your consent to the above.