Pre-Admission Form
Personal Details
Is the person completing this form the patient?
Yes, I am the patient
No, I am a carer
Name of the carer completing this form
First Name
Last Name
Patients Full Name
*
First Name
Last Name
Preferred Name
Date of birth
*
-
Day
-
Month
Year
Date
Age
Gender
*
Male
Female
Other
Occupation
*
Marital Status
*
Never married
Married
Divorced
De Facto
Separated
Widowed
Not stated
Country of Birth
*
Language
*
Indigenous status
*
Aboriginal
Torres Strait Islander
Aboriginal and Torres Strait Islander
South Sea Islander
Non Indigenous
Religion
*
Catholic
Hindu
Buddhist
Jewish
Muslim
None
Other
Patient address and contact details
Address
*
Street Address
Street Address Line 2
Suburb
State
Post Code
Phone Number
*
Email
*
example@example.com
Preferred contact
Phone number
Email
Back
Next
Save
NOK / Primary Carer
Name of Carer
*
Carer Phone Number
*
Please enter a valid phone number.
Is the Emergency contact the same as the Carer?
Yes
No
Name of Emergency Contact
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Relationship with Emergency contact
*
GP Details
GP Name
*
GP Phone Number
*
-
Area Code
Phone Number
Address
*
Street
Street Address
City
State
Postal Code
Insurance details
Do you have Medicare?
*
Yes
No
Medicare card number
reference #
Expiry
MMYY
Do you have a Healthcare or pension card?
*
Yes
No
Card Number
*
Do you have Private health insurance?
*
Yes
No
Health Fund
*
Member/Policy Number
*
Have you previously been a patient at Brisbane Day Hospital
Yes
No
Back
Next
Save
Gynaecological history
When was the first day of your last period?
*
-
Day
-
Month
Year
Date
Have you done a pregnancy test?
*
Yes
No
What was the result
*
Positive
Negative
Do you have any children? if so how many?
*
Have you had a Caesarean section?
*
Yes
No
How many/when?
*
Have you ever had an ectopic pregnancy before?
*
Yes
No
Please specify
*
When was your last Pap smear/CST?
Have you ever had an abnormal pap smear/CST result?
*
Yes
No
Please specify
*
When was your last STI screening?
*
Have you ever had gynaecological surgery?
*
Yes
No
Please specify
*
Are your periods
Regular
Irregular
Light bleeding
Moderate bleeding
Heavy bleeding
Mild cramping
Moderate Cramping
Painful cramping
No cramping
Back
Next
Save
Medical History
Have you had any previous surgeries or procedures?
*
Yes
No
Please specify
*
Have you or your family members ever had any reactions with anaesthetics?
*
Yes
No
Please specify
*
Do you have any allergies to medication?
*
Yes
No
Please specify
*
Do you have any other allergies or sensitivities?
*
Yes
No
Please specify
*
Are you taking any medications?
*
Yes
No
Please specify which medications you are taking and how often you are taking it.
*
Do you smoke?
*
Yes
No
Please specify how many per day?
*
Do you drink alcohol?
*
Yes
No
Please specify how much/how often
*
Do you use any recreational drugs?
*
Yes
No
Please specify which drugs & how much/how often
*
Are you currently Breastfeeding?
*
Yes
No
Do you have any loose or broken teeth?
*
Yes
No
Please specify
*
Do you have any respiratory conditions (e.g Asthma)
*
Yes
No
Please specify
*
Do you have any heart conditions? (e.g heart murmur, high/low blood pressure, palpitation etc)
*
Yes
No
Please specify
*
Do you have any bleeding or clotting conditions?
*
Yes
No
Please specify
*
Do you have diabetes?
*
Yes
No
Please specify which type and what treatment you are on
*
Do you suffer from heartburn/reflux/indigestion?
*
Yes
No
Please specify
*
Have you ever had any sexually transmitted diseases?
*
Yes
No
Please specify
*
Do you have Hepatitis A, Hepatitis B, Hepatitis C or HIV?
*
Yes
No
Please specify
*
Do you suffer from any psychological states? (e.g depression, bipolar, anxiety etc)
*
Yes
No
Please specify
*
Do you currently have any multi-resistant infections such as MRSA, VRE, or TB?
*
Yes
No
Please specify
*
Do you have any other medical condition(s)?
*
Yes
No
If yes, please specify
*
Save
Submit
Should be Empty: