PATIENT HEALTH QUESTIONNAIRE

PATIENT INFORMATION

PHOTO ID

Your Photo ID must be presented on the day of appointment, or our doctor cannot assess you. Your photo ID must be current and in the name of your booking. Support person ID is required. Interpreter ID is required. We do not accept Bank cards, Medicare card, or other ID without photo. Name changes: You must have evidence on the day, such as certificate of marriage or official government letter of name change, if booking is past name.


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MEDICATIONS

Please list all medications including Over the Counter (vitamins, Panadol etc) and prescribed medications taken.


CURRENT MEDICAL INFORMATION

PAST MEDICAL HISTORY

PAIN ASSESSMENT

Please complete below section, if applicable This section will provide your doctor with information on how you are feeling every day.

Pain scale = 0 no pain to 10 worst pain ever experienced.

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EDUCATION HISTORY

EMPLOYMENT (LIST ALL JOBS)

CHAPERONE

We are able to offer a Chaperone support for your examination.

FINANCIAL RESPONSIBILITY

DECLARATION

I (the form submitter), state the above personal information was:

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If this document was completed with the assistance of another person, please complete these details below:

PERSONAL INFORMATION CONSENT FORM

Privacy & Information Handling

Your personal and health information is handled in accordance with the Privacy Act 1988 and the Australian Privacy Principles.

Collection of Personal Information

To conduct your medical assessment, we will collect relevant personal and health information, including but not limited to:

  • Full name, date of birth, address and contact details

  • Medicare number and photographic identification

  • Medical history (past and current), medications and treating practitioners

  • Occupational, environmental and social history

  • Information provided by your referrer or third parties relevant to your assessment

All information is stored securely and protected against misuse, loss, unauthorised access, modification or disclosure.

We require your written consent to collect personal information about you and to use this information provided in the following ways:

  • To send examinee/claimant/patient communication reminder letters/recalls/SMS messages/emails; and

  • Billing purposes and administration purposes in the running of our practice

  • Disclosure to others involved in your healthcare

  • To comply with all legislative or regulatory requirements e.g. notifiable diseases

Consent for medical assessment:

  • I consent for my personal information being recorded in the ways listed above; and

  • I consent to undergo a medical examination with the Specialist Occupational Physician to whom I have been referred; and

  • I consent for the medical letter and or a report will be sent directly to the referrer; and

  • I consent to my assessing specialist accessing relevant medical information, including reports and investigation results, for the purposes of this assessment; and

  • I understand that my assessment will involve a detailed medical, work and social history and a relevant physical examination; and

  • I confirm that I have read the above consent to my satisfaction.

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Please return this Form and copy of PHOTO ID to info@occphyz.com.au 7 days prior to your appointment. Bring to your forms and PHOTO ID to the appointment on the day.

To view our practice Privacy Policy, please use this link below or scan the QR code on your device.

Link: OccPhyz Consulting Privacy Policy


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