SAMRA - New Patient Form

CONFIDENTIAL PATIENT REGISTRATION FORM
Patient Name

SalutationFirst NameLast Name
Address
Date of Birth

DayMonthYear
Date
Mobile Number

Area CodePhone Number
Gender
Cultural Identity: Do you identify as:
Cultural Identity: Do you identify as:

Aboriginal or Torres Strait IslanderNeitherPrefer not to say
Occupation
Email
example@example.com
Medicare Number
Expiry
Line Ref Number
Area/s of Treatment/Compliant (e.g L Knee)
Area/s of Treatment/Compliant (e.g L Knee)
If a patient under 18 years of age, please supply Medicare details and DOB for the Parent/Payer so we can send the claim online to Medicare
Parent Name/DOB/Medicare (if booking for a child)
Next of Kin Name
Next of Kin Relationship
Telephone
Usual/Family Doctor/GP
Address (Suburb)
Referring Doctor
Address (Suburb)
Physiotherapist/Other
Address (Suburb)
Practice Privacy Policy
This practice is, as a health provider in the private sector, bound by the National Privacy Principles and the Health Records and Information Privacy Act 2002
(NSW). These Principles set the standards by which personal information is collected from patients. A copy of these Principles is available from the Department of Health or the Australian Medical Association.

As part of your treatment, it is usual to write to your referring Doctor, the Physiotherapist involved in your care, and any other Specialists you are referred to, including imaging results, etc.

In the case of compensation matters, it may be necessary to write to the Insurers, Solicitor, Employer and/or rehabilitation provider. As outlined in the guidelines above, only the necessary information will be released.

For quality assurance and research, information may be extracted from your record and held on a specific secure database on occasion. It may be necessary for us to contact you for an ongoing assessment.

Unless otherwise indicated

I HEREBY AUTHORISE THE RELEASE OF MY MEDICAL HISTORY TO MY FAMILY DOCTOR/INSURANCE COMPANY/SOLICITOR (WHERE APPLICABLE).

I HAVE READ AND UNDERSTAND THE FEE AND CANCELLATION POLICY https://www.drdavidsamra.com.au/fee-page

I AGREE TO TAKE RESPONSIBILITY FOR THE PAYMENT OF ALL ACCOUNTS, PRIVATE OR INSURANCE.
Signature

Clear
Printed Name
Date

DayMonthYear
Date

Is this a current Workers Compensation or Third-Party Claim?

YESNO

To Be Completed for Worker's Compensation or Third-Party Claims
Insurance Company
Email
Fax Number
Claim Number
Contact Person (e.g. Case Manager
Email
Phone
Rehab Coordinator (if relevant)
Email
Phone
Employer
Address
Contact Person
Phone
Accident Details
Date

DayMonthYear
Date
Place
Brief Description
Signature

Clear
Date

DayMonthYear
Date
Print Name

INJURY MEDICAL QUESTIONNAIRE
Markup Image to show any areas of pain or concern
On the body map please mark the LOCATION of your current problem (if relevant)

If more than one area, please ensure you have prolonged consultation (45 minutes)
How long had you had this problem and was there an incident?

INVESTIGATIONS: Have you had any investigations to date

	Test Type (Xray, MRI, Bloods, Other)	Company & Suburb	Date (Month)
1
2
3
4
5

What treatment have you had to date?

EXERCISE: Outline your USUAL exercise regime below

	Exercise	Intensity	Frequency	Duration
1
2
3
4

What ACTIVITIES or EXERCISE do you enjoy most?

MEDICAL HISTORY:

List any conditions requiring treatment or surgery

YOU MAY OMIT THIS SECTION IF YOU HAVE A CURRENT GP REFERRAL WITH A HEALTH SUMMARY

MEDICAL HISTORY

	Body Area	Treatment/Operation	Year
1
2
3
4

MEDICATIONS (including vitamins/supplements)

	Name	Reason Taken	Dose (mg)	Frequency
1
2
3
4

List all allergies (medication, food, other)
FAMILY HISTORY

ArthritisDiabetesThyroid IssuesHeart DiseaseOther

	Not at all	To a slight degree	To a moderate degree	To a great degree	All the time
It's terrible and I think it's never going to get any better
It's awful and I feel that it overwhelms me
I become afraid that the pain will get worse
I keep thinking about other painful events
I can't seem to keep it out of my mind
I keep thinking about how much it hurts
I keep thinking about how badly I want the pain to stop

CONFIDENTIAL PATIENT REGISTRATION FORM