HARPER - New Patient Form

NEW PATIENT FORM
Title
Patient First Name
Patient Last Name
Date of Birth

DayMonthYear
Current Date

DayMonthYear
Age
Address
No. / Street
Suburb
State
Postcode
Mobile Phone
2nd Phone
Email Address
Occupation
Medicare No.
Ref No.
No. next to name
Expiry Date
(MM/YY)
Health Fund
Health Fund Membership No.
DVA
Pension No.
Expiry Date
(MM/YY)
Referring Doctors Name
Regular GP’s Name
Physiotherapist Name / Practice
Physiotherapist Email
WORKERS COMPENSATION & THIRD PARTY PATIENTS (CTP)
Insurance Company Name
Claim Number
Case Manager
Case Manager’s Phone
Case Manager’s Fax / Email
Employer
If applicable
Date of Injury

DayMonthYear
PRIVACY STATEMENT

As a patient of Dr Wade Harper, a medical record containing personal information will be maintained throughout your treatment. These records will contain information including, but not exclusive to, your name, address, date of birth, Medicare number and your referring doctor’s details. During the period of assessment and ongoing management, information of relevance is recorded in clinical notes. These records are stored securely and may be kept for up to seven years following your last consultation. If necessary, for the continuity of your medical care, this information may be shared with other health practitioners involved in your treatment. In certain circumstances, there may be a legal obligation to disclose clinical information. A full copy of our privacy policy is available on request.

I will take full responsibility for the payment of my accounts.
Patient Name
Patient Signature
Date

DayMonthYear
Problem Area

ShoulderElbowOther
Problem Side

RightLeftBoth
Are you right or left handed?

RightLeftAmbidextrous
Main problem is

PainInstabilityLoss of functionWeaknessStiffness
How long have you had symptoms?
Specify days / weeks / months / years
Was there an injury?

NoYes
Details
Separate each with a comma.
Pain Type

AcheSharpBurning
Pain Frequency

ConstantIntermittentOn certain movements
Severity: No pain (0) - Severe Pain (10)
Interferes with sleep?

NoYes
Do you need to take pain killers?

NoYes
Pain killers
Do you have any difficulty with

Overhead tasksGetting dressedDoing up braReaching walletDriving Hobbies (e.g. gardening)Playing sport

What treatments have you had

Rows	Session/No.	Benefit
Physiotherapy
Anti-inflammatories
Steroid injections

Other treatments
What investigations have you had?

XRULTRASOUNDCTMRI
Where did you have your investigations taken?

SPECTRUMCASTLEREAGHIMEDPRPOther
Background Health
Allergies to Medications

YesNo
If yes, please provide details
Separate with commas.
What happens
Regular Medications
Tick, if you take

WarfarinSteroidAspirinAnti-inflammatory
Do you smoke?

NoYes
How much?
Do you drink alcohol?

NoYes
How much?
General Medical Conditions (tick, if you have / have had)

DiabetesPrevious surgical infectionCancerDepression / Mental illnessHypertensionHiatus hernia / UlcersEpilepsyProsthetic Heart ValveThyroid diseaseKidney diseasePacemakerStrokeAsthma / BronchitisHeart attackHepatitisOther
If Other, please provide details
Previous surgery with a general anaesthetic

NoYes
Provide details
Patient Signature
Date

DayMonthYear
Have you booked an appointment to see Dr Harper?*

YESNOT YET
If you have not made an appointment to see Dr Harper,

Please call (02) 9650 4834 during business hours.
Should be Empty:

NEW PATIENT FORM

WORKERS COMPENSATION & THIRD PARTY PATIENTS (CTP)

PRIVACY STATEMENT

Background Health