Patient Area

Welcome to our Patient Area. Please click the links below to find more information or to download the relevant forms.

Patient Information Form

If you do not wish to fill in the Patient information form online you can download a PDF version of the form and fill it in manually. Patient Information Form(116 KB)

Patient Details

Title*

First Name*

Initial

Surname*

Street address*

Suburb*

State*

Postcode*

Date of birth*

Occupation*

Email*

Home phone

Work phone

Mobile phone

Do you wish to receive SMS reminders of your appointments?*
YesNo

Next of Kin*

Relationship*

Home phone

Work phone

Mobile phone

Referring Doctor

Referring Doctor's Name*

Date of Referral*

Address

Phone

Is your General Practitioner different from above?*
YesNo

Address

Phone

Health Insurance

Medicare Card No*

No. left of Name*

Expiry*

Do you have Private Health Insurance*
YesNo

Name of Health Fund

Membership No

No. Next to Name (if applicable)

Type of coverage
Hospital & ExtrasHospital OnlyExtras Only
Do you have any exclusions

Do you hold a DVA Card*
YesNo

DVA No

Colour of Card

Is this a WorkCover claim*
YesNo

Date of Injury/Accident

Date of Claim

Claim No

Case Manager (if known)

Phone (if known)

Insurance Company's Name

Insurance Company Phone

Employer's Name

Employer's Phone

Employer's Address

Sunshine Coast Neurosurgery ensures all measures are taken to protect the patient's privacy. In the event that we need to contact you, we will contact you on the above listed contact numbers. Should you have an answering service attached to the above contact number/s or if another member of your household answers, please include the consent to Sunshine Coast Neurosurgery leaving a message for you.*
CONSENTDO NOT CONSENT

Your Privacy, Our Concern -Consent to Use Your Personal Information

Sunshine Coast Neurosurgery complies with the Commonwealth Privacy Act and all other state and territory legislative requirements in relation to the management of personal information. We collect information that is necessary for the provision of your health care.Personal information obtained from you in your consultation may be used to provide information to various health services involved in supporting your health care management (e.g. pathology, radiology, hospitals or other specialists).

I have read and understood The Sunshine Coast Neurosurgey Privacy Policy and understand my rights and responsibilities.*
I hereby consent to my personal information being released as and when required.
Health Questionnaire Form

If you do not wish to fill in the Health Questionnaire form online you can download a PDF version of the form and fill it in manually. Health Questionnaire Form(116 KB)

Patient Details

First Name*

Surname*

Email*

Date of birth*

What is your height(cm)*

What is your weight(kg)*

Do you smoke?*
YesNo

How many cigarettes do you smoke per day?

Do you drink alcohol?*
YesNo

How much do you drink per day?

Treatment Area

LeftRightBoth

ShoulderElbowWristHand

HipKneeAnkle/FootNeck/Back/Pelvis

Medical History

Do you have or have you ever had the following conditions? Please answer every question and tick where appropriate.

Asthma, emphysema, shortness of breath or other lung problems*
YesNo

Diabetes*
YesNo

Diabetes controlled by
DietTabletsInsulin

Heart attack, palpitations, angina*
YesNo

Heart murmur*
YesNo

High blood pressure*
YesNo

Pacemaker or other heart implants*
YesNo

Elevated cholesterol/triglycerides*
YesNo

Stroke (CVA)*
YesNo

Epilepsy/fits/faints/funny turns*
YesNo

Stomach problems, gastric ulcer, indigestion or reflux*
YesNo

Bleeding or clotting disorder*
YesNo

Please specify the bleeding or clotting disorder

HIV/AIDS*
YesNo

Thyroid problems
YesNo

Cancer*
YesNo

Please specify

Kidney problems*
YesNo

Hepatitis/liver problems*
YesNo

Varicose veins*
YesNo

Deep vein thrombosis (blood clots in the legs)*
YesNo

Pulmonary embolus (blood clots in the lungs)*
YesNo

Previous blood transfusions*
YesNo

Do you take any blood thinning medication such as Aspirin, Warfarin, Plavix or anti-inflammatories?*
YesNo

Depression*
YesNo

Neck or back injuries/problems*
YesNo

Problems with anaesthetics, e,g vomiting*
YesNo

Do you have any current wound or skin breaks?*
YesNo

Have you ever had an MRSA (golden staph) infection?*
YesNo

Have you ever had a VRE infection?*
YesNo

Other*
YesNo

Please specify

Current medications: (including Herbal and/or Natural Therapies)

Allergies to medications/metals/other:

Previous surgery: (including dates if possible)

Any complications with previous surgery:

Any problems/complications with previous anaesthetics:

Which of the following causes you to become out of breath:
ExerciseClimbing stairsWalking on the flatAt restUnsure

Do you know your blood group:
YesNo

ABABO
PositiveNegative

I certify that the information given above is true and accurate to the best of my knowledge
Links to Hospital Admission Forms