Patient Questionnaire

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.

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.

General Medical History: (please circle where relevant)
Medication Name Medication Name
Family History:
Please indicate any neurological family diseases: