Patient Questionnaire

The patient questionnaire must be completed, in order to ensure that you are correctly identified in our records, to save you time, and to assist us in providing you with the best possible care.

You can download the patient questionnaire here.

Note

You can either print the confidential patient questionnaire and return via email or fax to 07 5503 2488 OR fill out our interactive patient questionnaire on your computer.

Title

First Name

Surname

Date of Birth

Age

Address

Postal Address (if different from above)

Phone (Home)

Phone(Work)

Phone (Mobile)

Occupation

Email Address

Emergency Contact Details (name and day/night time telephone numbers):

Medicare

Expiry:

Ref:

Veterans Affairs No:

DVA Gold Card:

Referring Doctor:

General Practitioner (if different to above):

Specialist(s) you are currently seeing:

The aim in this practice is for patients to be well-informed about their condition, and about any recommendations made for treatment. It is important therefore for you to say at the time if there is anything you do not understand, or about which you wish to know more. An exception to this occurs if you are referred for insurance or medico-legal assessment by a third party, when we are not at liberty to discuss your diagnosis or management

PATIENT ACKNOWLEDGEMENT AND CONSENT

I have read the information set out on this form. I agree with this information and hereby consent to my medical details including any medical reports being released to my referring medical practitioner(s) and to any other medical practitioner(s) who treats me now or in the future including any other medical practitioner to whom Coastal Neurophysiology refers me. My consent is based upon the understanding that such release is intended to be in the best interest of my health.
I hereby give authorisation for any of my past medical records to be released to Coastal Neurophysiology. To the best of my knowledge and belief all of the information I have provided is true and correct.

What are your main symptoms at present (relating to present referral)?

General Medical History: (please circle where relevant)

What is your current body weight?

What is your current height?

Amount of weight gain in past 12 months:

Amount of weight loss in past 12 months:

High blood pressure

If yes, is this medicated?

Yes No

High cholesterol and/or high blood fats

If yes, is this medicated?

Yes No

Diabetes

If yes, what is your average BSL

and how long have you had diabetes?

Obstructive lung disease (e.g. COPD, asthma) Chest wall disease (e.g. kyphoscoliosis) Hypercapnic respiratory Failure(increased CO2) Emphysema

Kidney disease Kidney stones Bladder problems

Gastric or duodenal ulcer Bowel disorder Liver disorder

Hepatitis A, B, C HIV

Currently or previously on treatment?

Yes No

Anaemia Excessive bleeding Other blood disorders

Thyroid disorder Other endocrine disorder

Anxiety Depression Other psychiatric disorder

Arthritis Joint or bone disorder

Epilepsy Seizures Blackouts Other neurological disorder

Smoking

If yes (number per day:

Have you previously smoked (age started:

age ceased:

Alcohol consumption

if yes, amount?

Min

Max

Avg

Any additional comments:

Do you take any non-prescribed or recreational drugs? (please specify)

Do you have any allergies? if yes, please list

Medication Name	Medication Name

Family History:

Please indicate any neurological family diseases:

Mother:

Father:

Maternal Grandmother:

Paternal Grandmother:

Maternal Grandfather:

Paternal Grandfather:

Location

8 Rawlins Street
Southport, QLD 4215

Contact

Phone: (07) 5503 2400
Bookings: (07) 5503 2499
Fax: (07) 5503 2488

Email

bookings@coastalneuro.com.au

Opening Hours

Monday 8:30-5:00
Tuesday 8:30-5:00
Wednesday 8:30-5:00
Thursday 8:30-5:00
Friday 8:30-5:00
Sat CLOSED
Sun CLOSED