PATIENT HEALTH QUESTIONNAIRE

PATIENT INFORMATION

Title

First

Middle

Surname

Dependent Children

Marital Status

DOB

Age

Sex

Address

Suburb

Postcode

Home Phone

Mobile

Work

Email Address

Country of Birth

Medicare Number

Ref

EXP Date (Month/Year)

Veteran's Affair No:

Dominant Hand

Weight (KG)

Height (CM)

BMI

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 yobooking. 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.

Driver Licence

Passport

18+ Card

other

Driver's Licence /Passport/Proof of Age card Number

Upload Proof of ID

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MEDICATIONS

Medication

Dosage

Frequency

Reason for taking

CURRENT MEDICAL INFORMATION

Current GP Clinic

Allergies

Pregnant

If yes, how many weeks?

Alcohol Usage

NeverOccasionallyRegularly

Alcohol Frequency

DailyWeekly

Type of Alcohol

Tobacco

NeverEx-SmokerYes

Tobacco Per Day

PAST MEDICAL HISTORY

Asthma and/or Lung Disease/ Illness

YesNo

If Yes to Asthma – Please provide further information

Diabetes

YesNo

If Yes to Diabetes – Please provide further information

Epilepsy

YesNo

If Yes to Epilepsy – Please provide further information

Back Pain / Neck pain

YesNo

If Yes to back pain – Please provide further information

Limb Joint pain or conditions

YesNo

If Yes to Limb/Joint – Please provide further information

Psychiatric Disorders e.g. Depression / Anxiety / Bipolar

YesNo

If Yes to Psychiatric/Bipolar– Please provide further information

Other medical conditions

YesNo

If Yes to other – Please provide further information

Please list your past operations or surgery

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.

1. Location of Pain – Please mark the following images where pain is felt

Clear drawing

Is your pain

IntermittentConstant

Does the Pain Radiate

NoYes

What makes the pain better?

What makes the pain worse?

EDUCATION HISTORY

Completed School level

Year 10Year 12Other

Qualification

EMPLOYMENT (LIST ALL JOBS)

Employer

Type of employment

Start Date

End Date

Reason for extended periods out of workforce: (family commitments, injury/illness, unable to find work etc.) Please describe

Have you served or currently serving in the Australian Defence Force or any other Military organisation?

NoYes

If Yes, please provide details

CHAPERONE

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

Would you like our staff member to be present for your examination only?

NoYes

FINANCIAL RESPONSIBILITY

Are you financially responsible for today’s consultation?

NoYes

DECLARATION

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

completed by me; and is true and correct to the best of my knowledge.

Signed *

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Todays Date

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

Name of person completing this document

Your Contact details

PERSONAL INFORMATION CONSENT FORM

Amendments to the Privacy Act 1988 brought the introduction of the Australian Privacy Principles (APP’s), whereby replacing the previous National Privacy Principles (NPPs) from 14 March 2014. These amendments redefined how healthcare services can manage your information.

OccPhyz Consulting aims to protect the privacy and secure storage of your health information at all times. We require you to provide us with your personal details and full medical history so that we may properly assess, diagnose, treat and be proactive in your health care. This includes your name, contact details, Medicare number and photographic identification. All personal information in relation to your visit is kept safely and securely within our practice.

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

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
To send patient reminder letters/recalls/SMS messages/emails regarding your health care.

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 give permission for my medical information be supplied to my Specialist if requested, in order for him/her to assess my health; 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.

Examinee/Patient Name

Date of Birth

Examinee/Patient Signature *

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Today Date