BEISCHER - New Patient Form

Patient Registration Form

MR ANDREW BEISCHER
Patient Details
Title
Surname
Given Name/s
Age
Date of Birth

DayMonthYear
Address
Suburb
State
Postcode
Email Address
Mobile
Home Phone
Business Phone
Next of Kin
Name
Relationship to Patient
Address
Phone
Referring Details
Referred By
Address
Local General Practitioner – if different to referring doctor
Local Doctor
Address
Podiatrist Details
Podiatrist Name
Address
Are you claiming as a: (please tick appropriate box)

Private PatientTransport Accident Commission (TAC)WorkCover
Private Health Insurance
Do you have Private Health Cover?

YesNo
If Yes, Name of Health Insurance Fund
Membership No.
Medicare No.
Ref No.
No. next to name
Expiry
(MM/YY)
WorkCover Details
Employer Name
Employer Address
Date of Injury

DayMonthYear
Insurance Company
Claim Number
Transport Accident Commission (TAC) Details
Claim Number
Date of Injury

DayMonthYear
Charges

ALL FEES MUST BE PAID AT THE TIME OF CONSULTATION
(by Visa / MasterCard / BankCard / EFTPOS / Cheque or Cash)
- Initial Consultation = $240.00
- Subsequent Consultation = $180.00
NOTE: TO OBTAIN MAXIMUM MEDICARE REFUND, A REFERRAL TO MR ANDREW BEISCHER IS REQUIRED

A PHYSIOTHERAPIST OR PODIATRIST REFERRAL IS NOT RELATEABLE FROM MEDICARE
Patient Signature

Clear
Date

DayMonthYear
General Medical History
Occupation
Do you smoke?

NoYes
If Yes…How much & for how long?
Are you an ex-smoker?

NoYes
If Yes…Please give details
Do you drink alcohol?

NoYes
If Yes…How much?
Do you suffer from any of the following?

Anxiety or DepressionAsthmaArthritisBleeding DisorderBlood ClotsBronchitisCancerCongenital DisorderDiabetesEmbolismEmphysemaGastrointestinal DisorderGoutHeart AttackOther Heart ProblemsHigh Blood PressureHepatitisHIV / AidsKidney StonesLeg ClotsPneumoniaOsteoporosisOther Lung ProblemRheumatoid ArthritisSkin DisorderStrokesTransfusionsUlcersVascular Disease
Other Diseases (Please list)
Separate with commas.
Do you take any Medications?

NoYes
If Yes…What Medications do you take?
Separate each with a comma.
Do you have any ALLERGIES?

NoYes
If Yes…Please list
Separate each with a comma.
Have you had any RELEVANT operations in the past?

NoYes
If Yes…What operations have you had?
Current Foot & Ankle Problem
Have you suffered an injury?

NoYes
When? (approximate date)
How?
Separate each with a comma.
How far can you walk? Please Tick Appropriate Box

Unrestricted4-6 Blocks1-3 BlocksLess than 1 Block
Do you suffer pain?

NoYes
If so, how would you rate your pain? Please Tick Appropriate Box

NoneMild (Occasional)Moderate (Daily)Severe (Almost always present)
Does your foot / ankle problem cause difficulty walking on some surfaces? Please Tick Appropriate Box

No difficulty on any surfaceSome difficulty on uneven surfacesSevere difficulty on uneven surfaces, stairs, incline, ladders
Are shoes a problem?

NoYes
What shoes do you wear because of your foot / ankle problem? Please Tick Appropriate Box

No restrictionComfort shoe wear (ie: runners)Custom or modified shoes / brace
How does the foot / ankle problem limit your activities? Please Tick Appropriate Box

No limitation at allNo limitation of daily activities but recreational activities are limitedLimited of daily & recreational activitiesSevere limitation of daily & recreational activities
Indicate the problems on the diagram if possible
Should be Empty:

Patient Registration Form

Next of Kin

Referring Details

Local General Practitioner – if different to referring doctor

Podiatrist Details

Private Health Insurance

WorkCover Details

Transport Accident Commission (TAC) Details

Charges

General Medical History

Current Foot & Ankle Problem