Patient Registration Form

New Patient Registration Form

Please complete the form below
Salutation (Title)
Patient Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Postal Address if different to Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number - Home

Area CodePhone Number
Phone Number - Mobile

Area Code (04)Mobile Number
Phone Number - Work (optional)

Area CodePhone Number
E-mail (optional)
Sex*
Date of Birth*

MonthDayYear
Marital Status*
What is your occupation
In case of emergency...
Emergency Contact:*

First NameLast Name
Relationship*
Contact Number*

Area CodePhone Number
Referring Doctors Name
Referring Doctors Clinic Name or Suburb
Referring Doctor Phone Number

Area CodePhone Number
General Practitioner, if different to Referring Doctor
General Practitioner Clinic Name or Suburb
General Practitioner Phone Number

Area CodePhone Number
Billing Information
Medicare Number

Medicare numberNo next to your nameExpiry Date
Health Fund Name:

NameMember No:Level of Cover (top, medium, extra's only)
Pension No

NumberExpiry Date
WorkCover / Third Party Claim Details
Employers name
Company Name
Contact Name
Who do you report to at work
Contact Number

Area CodePhone Number
Insurance Company Name
Company Name
Claim Number
Date of Injury

MonthDayYear
Details about your condition
Are you left or right handed*

LeftRightOther
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?*

YesNo
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*

YesNo
If yes, how many per day
Do you Drink*

YesNo
If yes, how many per day
Do you have any hobbies?*
Please list.
Have you been attending a physio or occupational therapist. If yes, who do you see?
Therapist / company name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number - Home

Area CodePhone Number
Radiology And Test Performed
Please list below any scans you have had performed, including the company name of where these were performed. We require this information to be able to view your scans online. If we do not have the correct information, we will not have access to this information.
X-rays
Ultrasound
MRI scan
CT scan
Nerve Conduction Studies
Which Company Performed The Above Tests

Alexandra Neurology (Dr Green)Brisbane Private ImagingCitiScanClinRadCorbett NeurologyDarling Downs RadiologyExact RadiologyImed RadiologyQLD X-rayQDI (Queensland Diagnostic Imaging)QScanRed RadiologyToowoomba Diagnostic ImagingOther
Medical History
Have You Had Any Previous Treatment For Your Condition. If Yes, Please Advise of What Treatment

NoYesOther
Do you have Diabetes?*

YesNo
If Yes, please list the medication are you taking for your diabetes or mark if diet controlled.
Do you have Heart Disease?*

YesNo
Do you have Asthma?*

YesNo
Do you have Low or High Blood Pressure?*

YesNo
Do you have Epilepsy?*

YesNo
Do you have any allergies?*

YesNo
If Yes, What are you allergic to
Please calculate your BMI*
Past Surgery or 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 immediately ceased from the date of authority in writing.I DO NOT 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.
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

MonthDayYear
Date
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New Patient Registration Form