Patient Registration Form

Salutation (Title)

Full Name

First NameMiddle NameLast Name

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Postal Address (If Different from Home Address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number (Home)

Area CodePhone Number

Phone Number (Mobile)

Area CodeMobile Number

Phone Number (Work)

Area CodePhone Number

Email

Sex

Date of Birth

DayMonthYear

Marital Status

What is your occupation?

In Case of Emergency...

Emergency Contact

First NameLast Name

Relationship

Contact Number

Area CodePhone Number

Referring Doctor's Name

Referring Doctor's Clinic Name or Suburb

Referring Doctor's Contact Number

Area CodePhone Number

General Practitioner (If Different from Above Doctor)

General Practitioner's Clinic Name or Suburb

General Practitioner's Contact Number

Area CodePhone Number

Billing Information

Medicare Details

Medicare NumberIndividual Reference NumberExpiry Date

Health Fund Details

NameMember NumberLevel of Cover

Pension Details

NumberExpiry Date

WorkCover / Third-Party Claim Details

Employer's Name

Contact Name

Who you report to at work

Contact Number

Area CodePhone Number

Insurer

Claim Number

Date of Injury

DayMonthYear

Details About Your Condition

Are you left or right handed?

Other

What condition are we seeing you about today?

How did the complaint / injury occur?

Date of Injury / Onset of Symptoms

DayMonthYear

Are you currently taking any medications?

If yes, what medications are you currently taking?

Please list your medications

What is your pain score at rest?

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Worst Pain

What are your main duties?

Do you smoke?

If yes, how many per day?

Do you drink?

If yes, how many per day?

Do you have any hobbies?

Have you been seeing a physiotherapist or occupational therapist?

Other

If yes, who do you see?

Therapist / Company Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Contact Number

Area CodePhone Number

Tests Performed

Please list any radiology, nerve conduction studies or other diagnostic tests you have had. Please include the modality (type of test), area tested (e.g. biceps), clinic or provider and date completed. This information helps us access your results as quickly as possible.

Radiology (CT, MRI, US, X-Ray, Etc)

Nerve Conduction Studies / Other

Medical History

Have you had any previous treatment for your condition?

If yes, please advise of what treatment.

Do you have Diabetes?

If yes, please list the medication are you taking for your diabetes (or note if diet controlled).

Do you have heart disease?

Do you have asthma?

Do you have any blood-pressure issues?

Other

Do you have epilepsy?

Do you have any allergies?

If yes, please list your allergies.

BMI (Body Mass Index)

Past Surgery / Procedures Performed

Other Known Illnesses

SOCIAL MEDIA CONSENT / RELEASE FORM

I CONSENT for Dr David Melsom to use my photo and/or information related to my medical condition and experience on his social medial platforms and/or below stated platforms and for educational purposes. I understand that this information may be used in publications, including electronic publications, audio-visual presentations, promotional literature, advertising, community presentations and media. I understand that I can revoke this release at any time in writing and that the use of any of my photos or other information authorised by this release will be immediately ceased from the date of authority in writing.

PRIVACY POLICY & CONSENT TO RELEASE OF MEDICAL INFORMATION

The provision of quality health care requires a doctor-patient relationship of trust and confidentiality. Consistent with our commitment to quality care, this practice had developed a policy to protect privacy in compliance with the privacy legislation.

It is necessary for us to collect personal information from patients and sometimes others associated with their health care in order to attend to their health needs and for administrative purposes.

In the interests of the highest quality and continuity of the patient’s health care, this may also include sharing information from other health care provides who comprise a patient’s medical team from time to time.

This practice will also send a letter to all relevant health care providers including the referring medical practitioner detailing the treatment provided.

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Name

First NameLast Name

Today's Date

Date

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