New Patient Pack

Dr Jehan Titus & Dr Jimmy Lam St Joseph’s Cottage, Calvary Hospital, 89 Strangways Terrace, North Adelaide SA 5006 Ph: 08 7231 0433 Fax: 08 8267 1821 Email: [email protected] NNEEWW PPAATTIIEENNTT PPAACCKK Dr Jehan Titus Dr Jimmy Lam (Pllease ciirclle whiich Dr you wiillll be seeiing) PLEASE COMPLETE THE ENCLOSED PAGES AND RETURN TO THE RECEPTIONIST AT YOUR APPOINTMENT Please contact our rooms if you have any queries regarding your appointment. Our friendly reception staff will be available to assist you Between9:00am – 5:00pm Monday to Friday Dr Jehan Titus & Dr Jimmy Lam St Joseph’s Cottage, Calvary Hospital, 89 Strangways Terrace North Adelaide, SA 5006 ABN: 60 435 211 679 Dr Jehan Titus & Dr Jimmy Lam St Joseph’s Cottage, Calvary Hospital, 89 Strangways Terrace, North Adelaide SA 5006 Ph: 08 7231 0433 Fax: 08 8267 1821 Email: [email protected] CONFIDENTIAL PATIENT INFORMATION PERSONAL DETAILS: Title: Dr/Mr/Mrs/Miss/Ms/Other: Date of Birth: Surname: Home Phone: Given Names: Mobile Phone: Preferred Name: Work Phone: Would you like to receive appt reminders via mobile phone SMS? YES/NO Email: Address: Suburb: Postcode: Postal Address: Your Marital Status: Suburb: Postcode: Are you a Diabetic? Yes / No FINANCIAL INFORMATION: Medicare Number: Exp Date: Private Health Fund: Medicare Reference (#NEXT TO YOUR NAME ON CARD): Membership number: DVA Number: Gold / White Level of cover: Hospital / Extras Pension card: Expiry Date: REFERRAL INFORMATION: Referring Dr: Address: Is this Dr your usual GP? Y / N Phone no: Usual GP (if diff from referring Dr) Address: Phone no: NEXT OF KIN DETAILS NOK Name: Home phone: Relationship: Mobile phone: Please Note: Full payment by cash, EFTPOS, credit card or bank cheque is requested on the day of consultation. Medicare and Private Health Funds do not fully cover the fees charged for consultations and procedures carried out in the consulting rooms. I accept personal responsibility for full payment of my accounts. Patient Signature: ………………………………….…… Date: …………………………………… Dr Jehan Titus & Dr Jimmy Lam St Joseph’s Cottage, Calvary Hospital, 89 Strangways Terrace North Adelaide, SA 5006 ABN: 60 435 211 679 Dr Jehan Titus & Dr Jimmy Lam St Joseph’s Cottage, Calvary Hospital, 89 Strangways Terrace, North Adelaide SA 5006 Ph: 08 7231 0433 Fax: 08 8267 1821 Email: [email protected] PATIENT HEALTH QUESTIONNAIRE NAME: _____________________________________ Do you have any current medical conditions? If so please list below: ......................................................................................................................................................................................................... ......................................................................................................................................................................................................... ......................................................................................................................................................................................................... ......................................................................................................................................................................................................... Have you previously had any type of surgery? If so please list below: ......................................................................................................................................................................................................... ......................................................................................................................................................................................................... ......................................................................................................................................................................................................... ......................................................................................................................................................................................................... Do you have any allergies? If so please list below ......................................................................................................................................................................................................... ......................................................................................................................................................................................................... ......................................................................................................................................................................................................... ......................................................................................................................................................................................................... Do you have a family history of serious illness/disease e.g. prostate cancer Yes / No If Yes please detail below ......................................................................................................................................................................................................... ......................................................................................................................................................................................................... EMPLOYMENT: Employed □ Unemployed □ Retired □ What is/was your occupation ............................................................................................................................................................ Do you smoke? Yes/No If “Yes” how many cigarettes per day? ___________ For ________ years If you are an ex-smoker how long ago did you quit?________ howmanyCigarettes per day prior to quitting? ________ Do you drink alcohol? Yes/No If “Yes” how many glasses ___________ per day / week / infrequent How much caffeine do you consume per day (per cup) Coffee ___________ Tea ___________ Cola ___________ Dr Jehan Titus & Dr Jimmy Lam St Joseph’s Cottage, Calvary Hospital, 89 Strangways Terrace North Adelaide, SA 5006 ABN: 60 435 211 679 Dr Jehan Titus & Dr Jimmy Lam St Joseph’s Cottage, Calvary Hospital, 89 Strangways Terrace, North Adelaide SA 5006 Ph: 08 7231 0433 Fax: 08 8267 1821 Email: [email protected] UUUrrrooolllooogggiiicccaaalll HHHeeeaaalllttthhh QQQuuueeessstttiiiooonnnnnnaaaiiirrreee Name: Date:_____________ Could you please describe your problem and the way in which it is bothersome. (Indicate by circling the degree of severity for each symptom) Your urinary symptoms Not at all Less than 1 time Less than half About half the More than half Almost always over the past month in 5 the time time the time 1. INCOMPLETE EMPTYING How often have you had a sensation of not emptying 0 1 2 3 4 5 your bladder completely after you have finished urinating? 2. FREQUENCY How often have you had to urinate again less than two 0 1 2 3 4 5 hours after you finished urinating? 3. INTERMITTENCY How often have you found you stopped and started 0 1 2 3 4 5 again several times when you urinated? 4. URGENCY How often have you found it difficult to postpone 0 1 2 3 4 5 urination? 5. WEAK STREAM How often have you had a weak urinary stream? 0 1 2 3 4 5 6. STRAINING How often have you had to push or strain to begin 0 1 2 3 4 5 urination? None 1 time 2 times 3 times 4 times 5 or more times 7. NOCTURIA Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night to the time you get up in the morning? Which of the above do you regard as most troublesome (1-7) If you were to spend the rest of your life with your urinary condition just the way it is now, how would Delighted Pleased Mostly satisfied Mixed Mostly Unsatisfied Unhappy Terrible you feel about that? Dr Jehan Titus & Dr Jimmy Lam St Joseph’s Cottage, Calvary Hospital, 89 Strangways Terrace North Adelaide, SA 5006 ABN: 60 435 211 679 Dr Jehan Titus & Dr Jimmy Lam St Joseph’s Cottage, Calvary Hospital, 89 Strangways Terrace, North Adelaide SA 5006 Ph: 08 7231 0433 Fax: 08 8267 1821 Email: [email protected] PATIENT CONSENT INFORMATION We require your consent to collect personal information about you. Please read this information carefully, and sign where indicated below. This medical practice collects information from you for the purpose of providing quality health care. We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. This means we will use the information you provide in the following ways: • Administrative purposes in running our medical practice. • Billing purposes, including compliance with Medicare and Health Insurance Commission requirements. • Disclose to others involved in your health care, including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following the referrals. • Disclose to doctors covering your doctor when on leave for the purpose of patient care. • Disclosure for research and quality assurance activities to improve individual and community health care and practice management. I have read the information above and understand the reasons why my information must

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