New Patient Form - Cervical Spine | Victorian Orthopaedic Spine Service

PATIENT DETAILS
Title*
Surname
Name*
First Name Preferred Name
Address*
Address Suburb Postcode
Date of Birth*
DD dash MM dash YYYY
Email*
Phone
Receive SMS
- PLEASE TICK IF YOU DO NOT WANT TO RECEIVE SMS MESSAGES FOR APPOINTMENT REMINDERS
MEDICARE NO.
PATIENT REFERENCE NO.
EXPIRY DATE
MM slash DD slash YYYY
NEXT OF KIN
NAME
RELATIONSHIP
PHONE
PHONE-II
PRIVATE HEALTH INSURANCE
DO YOU HAVE PRIVATE HEALTH INSURANCE?
- Yes
- No
FUND NAME
MEMBER NO.
VETERAN AFFAIRS NO.
COLOUR OF CARD
PENSION / HEALTH CARE NO.
EXPIRY DATE
MM slash DD slash YYYY
LOCAL DOCTOR
Name
Address
Address SUBURB POSTCODE
TRANSPORT ACCIDENT
- TRANSPORT ACCIDENT
CLAIM NO.
DATE OF ACCIDENT
MM slash DD slash YYYY
WORKCOVER
- WORKCOVER
CLAIM NO.
PART OF BODY INJURED
EMPLOYER
ADDRESS
CLAIMS OFFICER (NAME, TEL & FAX)
INSURANCE COMPANY
DATE OF INJURY
MM slash DD slash YYYY
SIGNIFICANT MEDICAL HISTORY
- DIABETIC
- ASTHMA / AIRWAYS DISEASE
- HEART DISEASE
- SLEEP APNOEA
- DO YOU TAKE ASPIRIN OR BLOOD THINNESS (PLEASE SPECIFY)
- PACEMAKER (PLEASE SPECIFY TYPE AND WHEN INSERTED)
- OTHER SIGNIFICANT MEDICAL HISTORY (PLEASE SPECIFY)
DO YOU TAKE ASPIRIN OR BLOOD THINNESS (PLEASE SPECIFY)
PACEMAKER (PLEASE SPECIFY TYPE AND WHEN INSERTED)
OTHER SIGNIFICANT MEDICAL HISTORY (PLEASE SPECIFY)
More Description
ALLERGIES - PLEASE SPECIFY
PAYMENT TERMS
- CONSULTATIONS: Payment is expected at the time of consultation.
- NON-ATTENDANCE: If 48 hours is not given for cancellation of an appointment a $50 fee applies.
- In the event an overdue account is referred to a collection agency and/or law firm, you will be liable for all costs which would be incurred as if the debt is collected in full, including legal demand costs.
- Overdue accounts will be subject to interest at the rate of 25% per annum, calculated for the period the account is due.
- I have been advised of costs for my consultation including telehealth fees.
I have read the above Payment Terms and agree to abide by them.
SIGNATURE
DATE
MM slash DD slash YYYY
PLEASE PRINT YOUR NAME
RELATIONSHIP TO PATIENT (EG SELF, PARENT, GUARDIAN)
Consent*
I consent to personal medical information such as test results being released to the following family members:
I consent to the handling of my information by Victorian Orthopaedic Spine Service for the purposes set out above, subject to any limitations on access or disclosure that I notify in writing to Victorian Orthopaedic Spine Service.
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PATIENT NAME
DATE OF BIRTH
MM slash DD slash YYYY
SIGNED
DATE
DD dash MM dash YYYY

Please score your pain – Neck and Arm
Please CLICK ON THE LINE on the bottom two scales to indicate the AVERAGE level of pain you have experienced over the last week where 0 is no pain and 10 is worst pain imaginable.
NECK PAIN: NECK DOWN TO TIP OF SHOULDER
ARM PAIN: BELOW THE TIP OF SHOULDER

DASS21
Please read each statement and select a number 0, 1, 2, or 3 which indicates how much the statement applied to you over this past week. There are no right or wrong answers. Do not spend too much time on any statement.
The rating scale is as follows:
0 Did not apply to me at all
1 Applied to me to some degree, or some of the time
2 Applied to me a considerable degree, or a good part of the time
3 Applied to me very much, or most of the time
I found it hard to wind down
I was aware of dryness in my mouth
I couldn’t seem to experience any positive feeling at all
I experienced breathing difficulty (eg excessively rapid breathing, breathlessness in the absence of physical exertion)
I found it difficult to work up the initiative to do things
I tended to over-react to situations
I experienced trembling (eg in the hands)
I felt I was using a lot of nervous energy
I was worried about situations in which I might panic and make a fool of myself
I felt that I had nothing to look forward to
I found myself getting agitated
I found it difficult to relax
I felt down-hearted and blue
I was intolerant of anything that kept me from getting on with what I was doing
I felt I was close to panic
I was unable to become enthusiastic about anything
I feIt I wasn’t worth much as a person
I felt I was rather touchy
I was aware of the action of my heart in the absence of physical exertion (eg sense of heart rate increase, heart missing a beat)
I felt scared without any good reason
I felt that life was meaningless

TAMPA
Please select one number for each question that most closely relates to how you feel about the statements below.
The rating scale is as follows:
1 Strongly disagree
2 Disagree
3 Agree
4 Strongly agree
I’m afraid that I might injure myself if I exercise
If I were to try to overcome it, my pain would increase
My body is telling me I have something dangerously wrong
My pain would probably be relieved if I were to exercise
People aren’t taking my medical condition seriously enough
My accident has put my body at risk for the rest of my life
Pain always means I have injured my body
Just because something aggravates my pain does not mean it is dangerous
I am afraid that I might injure myself accidentally
I am careful to not make any unnecessary movements is the safest thing I can do
(to prevent my pain from worsening)
I wouldn’t have this much pain if there weren’t something potentially dangerous going on in my body
Although my condition is painful, I would be better off if I were physically active
Pain lets me know when to stop exercising so that I don’t injure myself
It’s really not safe for a person with a condition like mine to be physically active
I can’t do all the things normal people do because it’s too easy for me to get injured
Even though something is causing me a lot of pain, I don’t think it’s actually dangerous
No one should have to exercise when he/she is in pain

New Patient Form – Cervical Spine

Cervical Spine – New Patient Form

Step 1 of 7

PATIENT DETAILS

NEXT OF KIN

PRIVATE HEALTH INSURANCE

LOCAL DOCTOR

PAYMENT TERMS

Patient History Form

INDICATE THE AREAS OF YOUR BODY WHERE YOU FEEL PAIN AND NUMBNESS, TINGLING OR PINS AND NEEDLES

Please score your pain – Neck and Arm

Oswestry 2.0: For Patients with Lower Spine and Leg Pain

Neck Disability Index – Initial: For Patients with Upper Spine Pain

DASS21

TAMPA