PATIENT MEDICAL HISTORY

PERSONAL DETAILS

TITLE *

FIRST NAME *

SURNAME *

DATE OF BIRTH *

ADDRESS *

Street address *

City *

State *

Postcode *

MOBILE *

HOME

EMAIL *

TYPES OF COVER

MEDICARE

REF NO

EXPIRY

DVA GOLD CARD

CONCESSION CARD NUMBER

PRIVATE HEALTH INSURER

POLICY NUMBER

LEVEL

EXCESS

NEXT OF KIN

FIRST NAME *

SURNAME *

RELATIONSHIP *

MOBILE *

Address different from patient

ADDRESS *

Street address *

City *

State *

Postcode *

PRIMARY GP

GP NAME *

GP CLINIC *

STREET ADDRESS

CITY *

STATE *

POST CODE

SOCIAL HISTORY

HOW DID YOU HEAR ABOUT US?

RELATIONSHIP STATUS *

EMPLOYMENT STATUS *

OCCUPATION

HAVE YOU EVER SMOKED? *

YESNO

IF YOU HAVE QUIT, WHEN WAS THIS?

IF YOU STILL SMOKE, HOW MANY PER DAY

DO YOU DRINK ALCOHOL? *

YES NO

IF YES HOW MANY PER DAY

PAST HEALTH

LIST ANY PREVIOUS MAJOR ILLNESS

LIST ANY MEDICATION YOU ARE CURRENTLY USING

YOUR VASECTOMY PROCEDURE

WHEN WAS YOUR VASECTOMY? *

WHO WAS THE DOCTOR? *

WHERE WAS THE PROCEDURE PERFORMED? *

PAIN

WHEN DID THE PAIN START? BEFORE OR AFTER VASECTOMY? *

DOES THE PAIN INTERFERE WITH WORK OR SEX? *

DOES THE PAIN WAKE YOU AT NIGHT? *

HAVE YOU SEEN ANY OTHER DOCTORS REGARDING THE PAIN YOU EXPERIENCE AND WERE ANY TESTS PERFORMED? (PLEASE BRING ANY INVESTIGATION RESULTS THAT YOU HAVE HAD) *

WHAT TREATMENT HAVE YOU TRIALLED TO DATE (PLEASE LIST ANY MEDICATIONS USED) *

Please discuss the nature of your pain:

Nature (sharp or dull)? *

Intensity of pain out of 10 (if 0 is no pain and 10 is extremely intense pain)? *

Where is the pain located? *

How long does it last for? *

When does the pain occur? *

How frequent is your pain? *

What percentage of the day is your pain present? *

What percentage of the week is your pain present? *

When does the pain stop? *

Does your pain radiate (spread out) and if so to where?

Is there anything that makes the pain worse or occur more regularly?

Is there anything that relieves your pain?

Are there any other questions you would like to discuss with the Doctor or any specific concerns? Please write them in the space provided here.

SPECIAL ALERTS / CLINICIAN ASSESSMENT

DO YOU HAVE ANY ALLERGIES? *

YesNo

PLEASE LIST

PREVIOUS ANAPHYLAXIS? *

YesNo

PLEASE EXPLAIN

LATEX ALLERGY? *

YesNo

INTERPRETER REQUIRED? *

YESNO

LANGUAGE

HAVE YOU HAD A RECENT INFECTION OR BEEN HOSPITALISED? *

YESNO

ALLERGIC TO IODINE? *

YESNO

DO YOU FAINT EASILY? *

YESNO

PRESSURE INJURY POTENTIAL *

YESNO

IF ALLERGIC TO MEDICINE PLEASE DESCRIBE:

COGNITIVE CONDITION

DO YOU HAVE A COGNITIVE IMPAIRMENT? *

YESNO

IF YES, ARE YOU RECEIVING SUPPORT UNDER THE CARE OF A DOCTOR?

DO YOU UNDERSTAND WHAT YOUR UPCOMING PROCEDURE IS – ARE YOU HEALTH LITERATE? *

YESNO

ARE YOU SPECIAL NEEDS (DEMENTIA, DOWNS SYNDROME, ENTERAL FEEDING, CEREBRAL PALSY E.T.C.) *

YESNO

ARE YOU ACCOMPANIED BY A CARER / GUARDIAN? *

YESNO

ARE YOU REQUIRED TO BE ACCOMPANIED BY A CARER / GUARDIAN? *

YESNO

Digital Signature *

Draw signature|Type signatureClear