Patient Registration Patient Registration Submisison Step 1 of 12 8% Unique IDTitle(Required)Please enter your title !Select titleMrMrsMsMissMasterDrProfA.ProfReverandPlease choose a title. Firstname(Required) Lastname(Required) Preferred nameYour 'preferred name' ! Date of Birth(Required)DD slash MM slash YYYY Enter your date of birth (dd/mm/yyyy) AgeGender(Required)MaleFemalePrefer not to sayAddress(Required) Unit/House No Street City State ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Healthcare EligibilityHealthcare Eligibility(Required)MedicareDVA - GoldDVA - WhiteWorker's CompThird PartyOverseas Visitor / StudentOther10-digit Medicare No(Required)IRN(Required)Please enter the number next to your name (IRN or Individual Reference Number) Expiry DVA - Gold DVA - White Please enter the date of injury !DD slash MM slash YYYY Please enter the date of injury ! Claim No Claim's OfficerInsurance DetailsPrivately Insured(Required) Yes No Healthfund Membership No ExpiryMM/YY Employment DetailsEmployment Status(Required) Employed - Other Self-employed Retired Home-maker Student Disability Pension Employer Occupation(Required) Contact Information & NOK DetailsHome PhoneWork PhoneMobile Phone (Self/NOK)(Required)RequiredEmail(Required) Enter Email Confirm Email Preferred method of contact(Required) Mobile Phone Home Phone Work Phone Email Mail (Residence) Mail (PO Box)Select AllSMS Appointment Reminders(Required) DO NOT USE SMS for Appt reminders SMS Appt reminders allowedEmergency Contact Emergency Contact Person(Required) Emergency Contact Phone/Email(Required)NOK/Emergency contact details Ethnicity & Other informationCountry of Birth(Required) Australia OtherCountry of Birth - Please chooseAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweATSI StatusAre you Aboriginal?(Required) Yes NoAboriginality Neither Aboriginal nor Torres Strait Islander Aboriginal but not Torres Strait Islander Torres Strait Islander but not Aboriginal Aboriginal and Torres Strait Islander Marital status and living situationMarital Status(Required) Single De facto Married Separated Divorced WidowedLiving Situation(Required) Alone With family Rest Home Hostel Caravan Nursing HomeMobility, Continence & Personal CaresContinence(Required) Continent Urinary incontinence - self catheterization Urinary incontinence - permanent catheter Urinary incontinence - incontinence pads Bowel incontinence - incontinence padsMobility(Required) Independent Walking Stick / Crutches Walking Frame Wheel chair Mobility Scooter Bed-boundPersonal Cares(Required) Self-caring Needs supervision Moderately Dependent Fully Dependent Smoking and Alcohol HistorySmoking status Never smoked Current smoker Casual smoker Ex-smokerSmoking (quantity) Only on social occasions Only when I drink alcohol 5 - 10 cigs daily 0.5 - 1 pack daily 1-2 packs daily 2 or more packs daily OtherWhen did you quit smoking?In the last 6 monthsIn the last 6 - 12 months12 - 24 months ago> 2yrs ago but < 10 yrs> 10 years agoDo you drink alcohol?(Required) Yes NoHow often do you drink alcohol?(Required) Less than monthly 1-2 days per month 1-2 days per week 3-4 days per week Every dayHow much alcohol do you drink each time?(Required) 1-2 standard drinks 2-4 standard drinks 4-6 standard drinks > 6 standard drinksHave you ever felt you needed to Cut down on your drinking?(Required) Yes NoHave people annoyed you by criticizing your drinking?(Required) Yes NoHave you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?(Required) Yes NoHave you ever felt Guilty about drinking?(Required) Yes NO Referral informationReferred by(Required) GP Specialist Private Hospital (LMPH, NPH, MPH) Public Hospital (JHH, BEL, CMH, MPH) Friend / Family Other Who is your usual GP?(Required)Please report your usual GP; otherwise enter NONE Usual GP Practice(Required)Please enter name of your usual GP Surgery; Enter NONE if you don't have a regular GPe.g. headache, dizzy spells, blackouts, tremors (Please enter referral reason in detail **)Reason for Referral(Required)I have had this problem for (duration):(Required) Days Weeks Months Years Othere.g. worried about brain tumour; NONE if you have no concerns to discuss (*Please state NONE if you don't have any specific concerns)Any specific concerns?(Required)I have a past medical history of:(Required) NONE OF THE ABOVE Prior Stroke/TIA Heart disease High blood pressure High cholesterol Peripheral vascular disease Diabetes Mellitus Asthma Kidney Stones Reflux Osteorthritis Anxiety/Depression Migraines/Headaches Blackouts / Funny turns Dizziness / Vertigo Parkinson disease Epilepsy Multiple sclerosis Medication historyI have the following medication allergies:(Required) Yes NoI am allergic to:(Required)Please list your allergies here!I take the following medications:(Required) NONE OF THE ABOVE Blood thinners (aspirin / clopidogrel) Anticoagulants (warfarin, NOAC) Anti-epileptics Anti-depressants Steroids Immunosuppressive drugs Biological agents Depot injections Medication patches (e.g. fentanyl) Eye drops Opiods/sleeping pillsAre you on any prescription or non-prescription medications?(Required) Yes NoPlease list your current medications (1 drug per line *e.g. Aspirin 100mg daily or NOT ON ANY MEDICATIONS)Current medicationsPlease upload a snapshot of your medications here (using your phone camera) Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 5 MB, Max. files: 5. If you have a webster pack or want to upload a snapshot of your medication or your webster pack, please use your phone/tablet camera to take a snapshot and upload the file securely ! Family medical historyIn my family, there is a history of?(Required)Please select any relevant family history ! Stroke/TIA High blood pressure High cholesterol Diabetes Heart disease Reflux Cancer Brain aneurysm Epilepsy Headaches/migraines Tremors Parkinson disease Dementia Multiple sclerosis Epilepsy Anxiety/Depression PTSD Bipolar disorder Kidney stones Genetic conditionDetailsIf you have said 'Yes' to any of above conditions, please record any details you may wish to disclose !Is there any other family history you wish to disclose?(Required) Yes NoOther family historyPlease describe Upload Results or ReportsPlease upload your results or reports here !Do you have any results or reports to upload?(Required) Yes NoUpload File Drop files here or Select files Max. file size: 2 MB, Max. files: 5. You can upload a maximum of 5 files; please ensure that each file is under 2mb CorrespondenceWe do not routinely send out copies of consultation letters to patients unless explicitly requested. Please advice reception if you need a copy of your consultation letter. Emailed copies do not incur any additional administrative charges but emails can only be sent to nominated addresses on this form! Otherwise postal copies will be charged at $10 per copy to cover our administrative expenses !Authorisation & ConsentWe are bound by Australian Privacy Laws. Please speak to reception if you need a copy of our privacy policy which is available in the reception area !Acknowledgement(Required) I consent to the use of my personal health information by Pacific Neurology / Dr Krishnamurthy and other health providers who are / may be involved in my medical treatment and health care. I consent to the disclosure of my personal health information to the above named practice and other health providers directly or indirectly invovled in my personal health care or medical treatment. I consent to Pacific Neurology requesting my health related information from other providers including allied health, other doctors and/or Public/Private Hospitals.Select AllCOVID-19 VACCINATION STATUS(Required) Fully vaccinated Partially vaccinated Unvaccinated - NOT EXEMPT Unvaccinated - Medical EXEMPTIONMy Health RecordI consent to uploading my health information to MY HEALTH RECORD (reports, results, correspondence etc)(Required) Yes NoPlease indicate your consent regarding uploading of your medical information to My Health Record (only applies to reports or results that are directly related to this or any future appointments*) I DO NOT CONSENT to the uploading of my health information to MY HEALTH RECORD Yes NoSignature Date(Required)DD slash MM slash YYYY Please select !CAPTCHAPDF Preview Δ
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