Dr Wong Patient Details Form

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Dr Su-Min Wong - New Patient Form

This form collects personal information and medical history and assists your doctor in providing comprehensive, safe and effective care.

Smart Health treats all information submitted confidentially and securely in accordance with our Privacy Policy. 

Please complete all sections as accurately as possible prior to your appointment.

It typically takes less than 15 minutes to complete.

Patient Details
Emergency Contact
Regular GP/Referring Practitioner Details
Medicare, DVA, Pension & Health Insurance Details
NDIS/LSA participant
Will this consultation be a WorkCover OR Motor Accident claim?
Medical Information & History

List all medications, over the counter medications and supplements you are taking

For each list Medication, Dose, Time taken, Side effects, if any and Benefit 

Do you currently smoke?
Do you consume alcohol?
Have you ever used recreational drugs?

Please list any other treatment providers you are/have seen for your current pain/injury/reason for consult:

Have you ever had the following investigations for your current pain/injury/reason for consult, if so, where?

Medical history (attach a separate list if necessary). For each list Treatment, Provider name and practice, Frequency of treatment:

Relationship status
Children status
Current hours of work

MEDICAL EXAMINATION AND INFORMATION PRIVACY POLICY


You have been referred to attend this specialist clinic to be medically assessed and managed by Dr Su-Min Wong.  Dr Wong is a Rehabilitation Medicine Physician who specialises in treating those affected by function limiting physical orcognitive conditions due to illness or injury. This may include musculoskeletal disorders, occupational injuries, pre andpost joint surgery, post trauma, brain injury, spinal cord injury, stroke, and other complex neurological orneurodegenerative disorders.

Your initial assessment may take between 30 to 60 minutes ( or more), depending on the complexity of your condition. Itis encouraged, but not necessary, that you have someone to accompany you for the consultation. The consult would entail a detailed history from you, followed by a detailed, targeted physical examination.  In order to best support your care, contact and correspondence with your other treating health professionals is usually required. To allow this, you are asked to sign a consent form for exchange of information with your other health providers. If you have any concerns or specific exclusion clauses, please note this on your form prior to your first appointment, or notify staff of any changes at subsequent reviews.

This practice is committed to protecting your privacy in accordance with national Australian Privacy Principles (APPs),which were introduced into the Privacy Act 1988 (Cth) in March 2018. The type of information we may collect and hold includes (but not limited to):

• Your full name, address, date of birth, employment details, email/contact details

• Medicare number, DVA number and other government identifiers,

• Health Insurance details

• Other health information, including: notes of your symptoms or diagnosis, specialist reports, test results, appointment &billing details, prescriptions, family history and other information (e.g. race).

The information is stored on an encrypted electronic medical record, which is accessible only to staff on a “need to know”basis. Staff and contractors are bound by confidentiality agreements. The practice has document retention and destruction policies.

Signed Consent:

I consent to the handling of my information by this practice for the purposes and in the manner outlined above. I also understand and consent to the relevant physical examinations. I understand that I am not obliged to provide anyinformation requested of me, but failure to do so might compromise the quality of health care and treatment I receive.

Consent: I consent to the handling of my information by this practice for the purposes and in the manner outlined above. I alsounderstand and consent to the relevant physical examinations. I understand that I am not obliged to provide anyinformation requested of me, but failure to do so might compromise the quality of health care and treatment I receive.

I consent

I CONSENT FOR DR SU-MIN WONG TO OBTAIN AND RELEASE MEDICAL INFORMATION RELEVANT TO MY HEALTH CONDITION WITH OTHER HEALTH CARE PROFESSIONALS INVOLVED IN MY CARE

* Your information will not be given to 3rd parties (employer, lawyer, insurers etc) without your specific consent.

I consent
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