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Pain Management Clinic

Pain Management Team

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Contact NIPM

Enquiries - All Locations

Phone: (02) 4923 8900

Fax: (02) 4947 8991

General Email Enquiries

Patient Information Form

Please allow 20 minutes to complete this questionnaire below in its entirety.

If you have any questions, please phone our rooms on (02) 4923 8900.

Fill out the form below

Patient Information Sheet

Step 1 of 6 - Personal Details

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Personal Information

Title(Required)

First Name(Required)

Family Name(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Email(Required)

Home Phone

Work Phone

Mobile Phone(Required)

Address(Required)

Address Line 1 Address Line 2 Suburb State Postcode

COMMUNICATION CONSENT REQUIRED(Required)

Please select each option that you provide your consent for.

SMS REMINDERS: I consent to receiving SMS reminders for appointments, recalls and other reminders relevant to my care.

EMAILS; I consent to receiving correspondence via email to the above email address, even though it is not considered a secure means of communication?

MHR; I consent for my Doctor at NIPM to access, view and upload to ‘My Health Record’.

I do not consent to any of the above.

Are you on blood thinning medication?(Required)

Yes

No

Name of your blood thinning medication:(Required)

Are you Diabetic?(Required)

Yes

No

Do you take insulin?(Required)

Yes

No

Do you have any allergies?(Required)

Yes

No

Allergies(Required)

How did you hear of us?(Required)

Account Details

Fund type for your care at NIPM?(Required)

Aged Pension

Uninsured

Private

DVA Gold

DVA White

ADF

WC

CTP

Medicare Number(Required)

Number next to name(Required)

Expiry Date(Required)

DD slash MM slash YYYY

Are you in a health fund for hospital cover?(Required)

Yes

No

Name of Health Fund(Required)

Membership Number(Required)

Do you have a pension card?(Required)

Yes

No

Pension Type(Required)

Pension Card Number(Required)

Expiry Date(Required)

DD slash MM slash YYYY

Veterans Affairs Card Number(Required)

White Card Condition(Required)

EPID(Required)

At which base are you located?(Required)

Employers Name(Required)

Insurers Name(Required)

Claim No.(Required)

Date of Injury

DD slash MM slash YYYY

Case Managers Name(Required)

Case Managers Phone or Email(Required)

Nominated Treating Doctor (NTD) Name(Required)

NTD Suburb(Required)

NTD Phone Number(Required)

Do you have a rehab provider involved in your care?(Required)

Yes, I would like them included in correspondence

Yes, but I do not want them involved in my care

No

Rehab Providers Name(Required)

Rehab Providers Phone or Email(Required)

Your Medical Providers

Were you referred by a GP or a Specialist?(Required)

GP referrals are valid for 12 months. Specialist referrals are valid for 3 months.

Specialist

GP Referral

Who is your referring Doctor?(Required)

Referring Doctors address(Required)

City or Suburb State

Who is your regular GP?

Referring GPs Address

City or Suburb State

This field is hidden when viewing the form

Third Party Details

This field is hidden when viewing the form

Is this a workers compensation/CTP claim?(Required)

Yes

No

This field is hidden when viewing the form

Employers Name(Required)

This field is hidden when viewing the form

Insurers Name(Required)

This field is hidden when viewing the form

Claim Number(Required)

This field is hidden when viewing the form

Case Manager(Required)

This field is hidden when viewing the form

Case Manager Phone(Required)

This field is hidden when viewing the form

Nominated Treating Doctor (if applicable)(Required)

This field is hidden when viewing the form

NTDs Address(Required)

City or Suburb State

This field is hidden when viewing the form

Rehab Providers Name

Without your prior written consent, we are unable to liaise with your rehab provider.

This field is hidden when viewing the form

Rehab Providers Email Address or Phone Number

Next of Kin / Permission to Communicate

I give my permission for NIPM to communicate with the following persons regarding my appointments and/or treatment (e.g. Spouse, Parents, Children, etc.);(Required)

Yes, persons listed below.

No. I do not authorise communication with anyone other than myself.

Permission to Communicate, Contact 1

Name(Required)

Relationship(Required)

Contact Number(Required)

Permission to Communicate, Contact 2

Name

Relationship

Contact Number

Permission to Communicate, Contact 3

Name

Relationship

Contact Number

What type of consultation are you attending?

Are you coming for a PAIN or an ANAESTHETIC consultation, on this occasion?(Required)

Pain Management

Anaesthetic Consultation

Psychology

Pain Management Specific Questions

Height (cm)(Required)

Weight (kg)(Required)

Occupation(Required)

What is your main concern for coming to see a Pain Specialist on this occasion?(Required)

How did your major pain concern begin (tick one box only)?(Required)

Cancer

Medical Condition, other than cancer

Injury at home

Injury at Work

Injury at - other

Motor Vehicle Accident

Other

How long has your pain been present (tick one box only)?(Required)

Less than 3 months

3 to 6 months

6 to 12 months

12 months to 2 years

2 to 5 years

More than 5 years

Do you have any of the following?(Required)

PTSD

Anxiety

Depression

Other mental health condition

Diabetes

High blood pressure

High cholesterol

Heart and circulation problems

Arthritis (including Rheumatoid/Osteoarthritis)

Muscle, bone and joint problems other than arthritis (including Osteoporosis, Fibromyalgia)

Digestive problems (including IBS, GORD, Stomach Ulcers, Reflux, Bowel Disease)

Respiratory problems (including Asthma, Lung Disease, COPD, Sleep Apnoea)

Neurological problems (including Stroke, Epilepsy, Multiple Sclerosis, Parkinson’s Disease)

Cancer Liver, kidney and pancreas problems (including Pancreatitis, Kidney Disease)

Thyroid problems (including Hyperactive or Hypoactive Thyroid, Graves’ Disease)

Other medical conditions not listed above

No medical conditions

Who are the people involved in your care? (Doctors, Psychologists, Physio, etc.) Please include their names & suburbs.

I consent for my treating provider to liaise with any of the providers listed above.(Required)

Yes, I consent.

No, I do not wish for you to speak to anyone other than my referring Doctor, Nominated Treating Doctor (NTD) or GP.

Have you had any tests or scans in the past 3 years that are directly related to why you are seeing the Pain Specialist?(Required)

Yes

No

Acknowledgment(Required)

I will bring copies with me to my appointment

I will ask my GP to forward these to you

I dont know what I had, or where I had these done

Current list of Medications

Please provide a full list of your medications, as well as the dosage of these.

Anaesthetic Specific Questions

Height (cm)(Required)

Weight (kg)(Required)

How would you consider your overall health?(Required)

Poor

Average

Good

Excellent

Do you have sleep apnoea?(Required)

Yes

No

Do you have a diagnosis of any heart problems?(Required)

Yes

No

Who is your Cardiologist?(Required)

Cardiologist Address(Required)

City or Suburb State

Have you had major problems with anaesthesia in the past?(Required)

Yes

No

Please describe details below;(Required)

Do you have any loose teeth, dentures or crowns?(Required)

Yes

No

Please describe details below;(Required)

Permission to Collect & Store Information

Patient Full Name

Date(Required)

DD slash MM slash YYYY

Acknowledgement (Release & Obtain Medical Records)(Required)

I authorise Dr Simon Tame, Dr John Prickett, Dr Hasher Kadavil, Dr Steve Bruce and Dr Mike Shelley to release or obtain medical information to or from the referring doctor, general practitioner, insurance company, solicitor or other health professionals in matters concerning my health.

Yes, I consent.

No, I do not consent.

Acknowledgement (Fees)(Required)

I understand that payment of consultation fees is payable at the time of appointment.

Yes, I understand.

No, I do not understand.

Patient Signature(Required)

If you are a signing on behalf of the patient;

Name

Relationship

Contact Number

As you will be a patient of our practice, we require you to provide us with your personal details. We may also need to collect and store information about you, so that we may properly assess, diagnose and treat your health care needs. Information may be collected and stored in paper, electronically or both. We aim to protect the privacy of your health information. We require your consent to collect your personal information, and for its use in the following ways:

Administrative purposes.
Billing purposes (including compliance with Medicare and Health Insurance Commission requirements).
Disclosure to others involved in your healthcare. This includes your treating doctor and specialists outside this practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following referrals.
Disclosure to other doctors in this practice for the purpose of patient care and teaching.
Disclosure to your solicitor, insurance company and other health professionals in matters concerning your health.
For research and quality assurance activities to improve individual and community health care and practice management. Only information that does not identify you is used in these circumstances.
To comply with any legislative or regulatory requirements, such as notifiable diseases, and where we are compelled by law.
For reminders and recalls which may be sent to you regarding your health care and management.

You can decline to have your health information used in all or some of the ways outlined above but it may influence our ability to manage your health care to provide the best outcome for you.

Please tick each field to acknowledge you have read and accept how we will store your information at NIPM.

I have read the information above and understand the reasons why my information must be collected.

I have supplied true and accurate information within this form, to the best of my ability.

I understand that I am not obliged to provide any information requested of me, but failure to do so may compromise the quality of health care and treatment given to me.

I am aware of my rights to access the information collected about me, except in some circumstances where access may be legitimately withheld. I will be given an explanation in these circumstances.

I understand that if my information is to be used for any other purposes other than set out above, my further consent will be obtained.

I consent to the handling of my information by the practice for the purpose set out above, subject to any limitations on access or disclosure of which I notify this practice.

I understand that if another treating provider is mentioned during my consultation/ treatment about past medical history, we may communicate with them to obtain further information, or provide information to them about your care at the clinic if the clinician feels it is important they know.

I understand that some practitioners within NIPM utilise a note taking tool called Heidi to accurately and efficiently capture the details of your discussions and the outcomes of appointments. Your consent is crucial for us to use this technology. Please understand that your information will be handled with the utmost care, and Heidi’s use is aimed solely at improving your healthcare experience.

OR

I am unsure and would like to discuss this further with someone from the practice before I sign.

My Health Record(Required)

I understand that My Health Record will be used at this practice, if required, to access my record and sometimes to upload information. Your permission to do so is automatic (per the My Health Records Act 2012), unless you express otherwise.

I do not want my information shared with My Health Record

Patient Name(Required)

Date(Required)

MM slash DD slash YYYY

Patient/Guardian Signature(Required)

Name of Guardian (if applicable)

Relationship

Phone Number

Name

This field is for validation purposes and should be left unchanged.

Enquiries
All Locations

Phone: (02) 4923 8900

Fax: (02) 4947 8991

Email: Click Here

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