Patient Consultation Form – Dr Islam Nassar

Patient Information

First Name

Last Name

Date of Birth

Home Number

Mobile Number

Email Address

Home Address

Suburb

State

Post Code

Height

Weight

Occupation

Referral Information

Referring Doctor Name

Medical Practice

Practice Tel

Practice Email

Usual GP Name

Medical Practice

Practice Tel

Practice Email

Imaging @

Pathology @

Physiotherapist Name

Physio Practice

Practice Tel

Practice Email

Any Other Relevant Medical Practitioners

Practice Tel

Practice Email

Medicare & Insurance Details

Medicare Number

Ref. No

Exp. Date

Private Health Insurance?

Yes No

Fund Name

Membership No.

Veterans Affairs Card

Yes No

Number

White Gold

Exp. Date

Self Fund Patient?

Yes No

Next of Kin Details

(family member or friend / medical power of attorney)

Next of Kin Name

Relationship to You

Mobile Number

In your own words what is the problem that you are seeing Dr Nassar about, how is it affecting your daily life, how long have you had this problem and, is it getting better or worse?

Pain Profile

Pain Location

Pain at Night/Rest

History of Injury to the Area

History of Surgery to the Area

Joint Profile

Approx. how far can you walk?

Any Sporting Activities?

What Aggravates Your Symptoms?

What Relieves Your Symptoms?

Have you had any previous operations or injections? If so, what procedures did you have and, were there any problems or complications?

Please List Any Specific Concerns / Questions You have regarding your injury/condition

Medication

Do you currently take any medications?
If yes, please list all medications, including prescribed, over-the-counter, herbal, vitamins, or pain relief. ( include the name, dose, and how often you take each)

Health Info

Do you suffer from diabetes?

Yes No

If yes:

Type 1 Type 2

Do you smoke/Vape?

Yes No

If yes, how much/week

Do you drink alochol?

Yes No

If yes, how many drinks/week

Do you have any allergies?

Yes No

If yes, list your reaction

We require your consent to collect personal information about you. Please read this information carefully and sign where indicated below.
ACCRA collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. We will use the information you provide in the following ways:

Administration purposes in running our medical practice.
Billing purposes, including compliance with Medicare, Health Insurance Commission, Workcover and Transport Accident Commission requirements.
Disclosure to others involved in your health care, including treating doctors, physiotherapists and other specialists outside the medical practice. This may occur through referral to other doctors or for medical investigations and in the reports of results returned to us following referrals.

I have read the information above and understand the reasons why my information must be collected. I am also aware that this practice has a privacy policy on handling patient information. I understand that I am not obliged to provide any information requested of me, but that my failure to do so may compromise the quality of health care and treatment given to me. I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances. I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained. I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure that I notify this practice of.

Signature

Name: (Please Print)

Date