Questionnaire

Details: Written by: Dr Stuart Myers; Published: 17 February 2022; Hits: 9836

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

Title *

Gender *

First Name *

Surname *

Date of Birth *

Address *

Include Suburb

Email Address *

Home Phone

Work Phone

Mobile Phone *

If no mobile phone insert contact person mobile number

Medicare Number

Ref

Medicare Expiry

Private Health Insurance

Membership Number

Insurance Type *

Is this Private, Public , Workers Comp, 3rd Party, or Veterans. Please note Dr Myers no longer works in the Public Hospital.

DVA Veteran Number/Type

Referring General Practitioner *

Usual General Practitioner (if different)

Physiotherapist / Other Interested parties / include contact details

If Patient is a Child

Age 16 years or less.

Parent Name

Parent Date of Birth

Medicare Card Reference Number

Parents Ref Number

Emergency Contact, Next of Kin

Name

Contact Number

Relationship

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.

Date of Injury

Claim Number

Insurer

Case Manager

Employer

Current Work Capacity

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.

Age *

Hand Dominance *

Right Hand Dominant

Left Hand Dominant

Ambidextrous

Which hand do you use to write with or perform most activities with?

Occupation / If retired what did you do previously *

Occupation Type

Clerical

Light Manual

Heavy Manual

Professional

Retired

Unemployed

Height (cm) *

Weight (Kg) *

Sport & Hobbies *

Sport & Hobbies Previous

If Different eg Gymnastics

Nature of Problem *

Eg Tendon rupture or fracture is an "Injury". Trigger finger or Carpal Tunnel Syndrome or "Overuse" is a "Condition"

Injury Details

If appropriate

Date of Injury

Side of Injury

Right

Left

Bilateral (Both)

What was Injured?

Details of Accident

How & Where did injury occur?

Hand Condition Details

If hand problem is not due to an injury.

Location of Symptoms

eg Hand , Fingers, Wrist

When did injury occur/symptoms start?

eg Days, Months , Years

Cause of Symptoms?

eg Unusual activity, Woke up with symptoms

How bad is your Pain / 10? *

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!

What can't you do as a result of the problem? *

What you do you take to relieve the pain? *

What treatment have you had so far? (indicate all relevant) *

None

Rest

Ice/Cryotherapy

Cast/Splint

Pain Killers

Anti-inflammatories

Injection/s

Physiotherapy

Surgery

What surgery or operation/s have you had?

List any other medical conditions or injuries

eg Fractured wrist as a child

Are there any conditions that run in your family?

eg Diabetes, Inflammatory arthritis, Psoriasis

Smoking *

Never

Ex Smoker

Smoke or smoked 0 - 10 / day

Smoke or smoked 10 - 20 / day

Smoke or smoked > 20 / day

Years Smoked less 0 - 10 yrs

Years Smoked 10 - 20 yrs

Years Smoked > 20 yrs

Smokers & Ex smokers may tick several boxes as approriate

Alcohol *

Never

1 - 5 drinks / week

6 - 10 drinks / week

11 - 15 drinks / week

16 - 20 drinks / week

> 20 drinks / week

Previously more

Do you have any Allergies? *

Yes

Please List any Allergies?

eg Penicillin,

Do you take any regular medications? *

Yes

What regular medications are you currently taking?

Are you taking any of the following blood thinners?

Warfarin

Plavix (clopidogrel)

Xarelto (rivaroxaban)

Eliquis (apixaban)

Aspirin/Cartia

Heparin

Clexane

Other

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

Where were Blood tests / Pathology performed?

Nil

SEALS

Douglass Hanly Moir

Laverty

SydPath

Other

Terms of Service

Consent *

Permission is given for Dr Myers to ask about and document your medical history and to perform an appropriate orthopaedic examination pertaining to your clinical history and medical condition.

If appropriate he may administer a Cortisone injection if your condition warrants it.

Permission is given to release the Medical History to the Family Doctor, Insurance Company or Solicitor (where applicable).All details given on this information Sheet will be kept in strictest confidence and I understand this questionnaire will form part of the decision making process and help guide and manage my treatment.
Dr Myers may use some of your details for the purpose of audit/or medical research. Please indicate your consent to the above.

Media Consent *

Yes

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.

Signature *

Date

First Name

Registration & Questionnaire