• New Patient Registration

    Please complete the form and submit at the end.
  • Gender*
  • Other Gender
  • Format: 0000 000 000.
  • Format: (00) 0000 0000.
  • Format: 0000 000 000.

  • Next of Kin Details

    Family Friend Medical Power of Attorney
  • Format: 0000 000 000.

  • Referring Doctor's Details

  • Format: (00) 0000 0000.

  • Your Payment Details

    What type of payment or claim will you require
  • Type of Payment or Claim*

  • Medicare Claim

  • Private Health Insurance

  • Workcover Claim

  • Date of Injury*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (00) 0000 0000.
  • Format: (00) 0000 0000.
  • Format: (00) 0000 0000.
  • Format: (00) 0000 0000.

  • DVA Claim

  • DVA Type*

  • TAC Claim

  • Date of Accident*
     - -
    2 digit month, 2 digit day, 4 digit year

  • About Your Pain

    What type of payment or claim will you require

  • Where Is Your Pain Located?

  • On the diagram, colour the areas where you feel pain and use different colours to describe the pain types.

    Sharp Pain (RED), Broad Ache (ORANGE), Pins & Needles (BLUE), Other (GREEN).

  • Your Recent Pain History

    During the past week, how severe was you pain?
  •

  • Your Pain's Impact

    During the past week, how much has pain interfered with your life?
  •

  • Your Pain's Impact

    During the past week, how much has pain interfered with your life?
  • Click to Select the picture that best describes the pattern of your pain over time*

  • Your Nerve Pain

    Mark one description from each statement that best fits your situation
  • Do you suffer from a burning sensation (eg. stinging nettles) in the marked areas?*
    Rows
  • Do you have a tingling or prickling sensation in the area of your pain (like crawling ants or electrical tingling)?*
    Rows
  • Is light touching (clothing, a blanket) in this area painful?*
    Rows
  • Do you have sudden pain attacks in the area of your pain, like electric shocks?*
    Rows
  • Is cold or heat (bath water) in this area occasionally painful?*
    Rows
  • Do you suffer from a sensation of numbness in the areas that you marked? *
    Rows
  • Does slight pressure in this area, e.g., with a finger, trigger pain?*
    Rows

  • Your Pain Medications

  • List the pain medications that you are taking right now (if none add NONE)*
    Rows
  • List the pain medications you have tried in the past (if none please add NONE)*
    Rows

  • Your Other Pain Treatments

    Please describe any other pain treatments and describe whether they were helpful or not. Where no treatment, please add NONE.

  • Your Social History

  • Are you currently working?*

  • Your Past Medical History

  • Please tick any condition that you have*

  • Your Past Surgical History

  • Please list including date and type of surgery
    Rows

  • Other Health Information

  • Calculate you Body Mass Ratio
  • List any current medications (exclude pain medications already listed).
    Rows
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  • Are you on blood thinning medications?*
  • Are you a diabetic?*
  • If yes, are you on an SGLT2 Inhibitor?*
  • Do you smoke?*
  • Do you drink alcohol?*
  • Do you take drugs not prescribed by a medical practitioner?

  • Your Pain Thoughts & Feelings

    Everyone experiences painful situations at some point in their lives. Such experiences may include headaches, tooth pain, and joint or muscle pain. People are often exposed to situations that may cause pain, such as illness, injury, dental procedures or surgery. We are interested in the types of thoughts and feeling that you have when you are in pain.
  • Listed below are 13 statements describing different thoughts and feelings that may be associated with pain. Using the scale, please select the degree to which you have these thoughts and feelings when you are experiencing pain.
    Rows

  • DASS 21

  • Please read each statement and check which indicates how much the statement applies to you over the past week. (there are no right or wrong answers. Do not spend too much time on any statement)
    Rows

  • Thank You

    All information collected by this practice will be used for providing healthcare. Collection, utilisation and storage of this information will be compliant with the 2001 Health Records Act. I consent to Dr Stiofan O’Conghaile collecting and storing my information. I also acknowledge that if I do not have the appropriate private insurance cover, I will need to obtain any further medical or surgical treatment through the public health system, and it is my responsibility to access this through my General Practitioner.
  • Today's Date
     - -
    2 digit day, 2 digit month, 4 digit year
  • How Did You Hear About Us
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