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dr chryssidis patient contact details form

1
Musculoskeletal Medicine - New Patient Form

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

This information assists your doctor in providing comprehensive, safe and effective care.

Our records are entirely confidential.

Patient Details
Birth Sex
Preferred Contact Method
Interpreter required?
Aboriginal or Torres Strait Islander Origin
Medicare Details
Pension Card Type
Regular GP Details
Permission to contact your regular GP/Practitioner regarding your care and progress?
Emergency Contact
Reason for Visit/Presenting Complaint
Onset of concern
Pain Quality
Associated Symptoms
Does your pain affect your sleep?
Have you had previous Pathology/Radiology relating to this current concern?
Have you had any previous treatment?
Other Symptoms
Unexplained weight loss?
Fever, chills, night sweats?
History of cancer?
Recent significant trauma
Progressive weakness?
Numbness in groin/saddle region?
Loss of bladder or bowel control?
Constant night pain or pain at rest?
Recent infection or IV drug use?
Osteoporosis or long-term steriod use?
Occupation & Social History
Does your work aggravate symptoms?
Smoking history
Vaping history
Consumption of alcohol
Recreational drug use
Do you have a spouse, partner or main support person?
Relationship status
Living situation
Do you have a carer or require assistance with daily activities?
Are you a carer for someone else?
Past Medical History
Are you, or could you be, pregnant?
Arthritis/Inflammatory Joint Disease
Osteoporosis
Chronic pain condition
Diabetes
Heart disease
HIgh blood pressure
Stroke
Respiratory disease (Asthma/COPD)
Kidney disease
Liver disease
Cancer
Mental health condition (anxiety/depression/PTSD)
Neurological disorder
Other significant condition(s)
Medications & Supplements
Are you currently taking any prescribed medications?
Are you currently taking any over the counter medications/supplements?
Are you taking anticoagulants (eg. Warfarin, Apixaban, Roxarivaben, Asprin)?
Have you had any recent cortisone medication or injections?
Allergies & Adverse Reactions
Do you have any known drug allergies?
Do you have an allergy to chlorhexidine (antiseptic)?
Do you have a latex allergy?
Do you have any other allergies (eg. food, environmental)?
Many people who experience ongoing pain notice changes in mood, stress or anxiety over time. The following questions help us better understand the overall impact of how pain is affecting you to enable us to support your recovery and provide treatment and care effectively.

Please rate how much each statement applied to you in the past week.

0 = Did not apply to me at all

1 = Applied to me to some degree

2 = Applied to me a considerable degree

3 = Applied to me very much or most of the time

Depression

I couldn't seem to experience any positive feeling at all
I found it difficult to work up the initiative to do things
I felt that I had nothing to look forward to
I felt that life was meaningless
I was unable to become enthusiastic about anything
I felt I wasn't worth much as a person

Anxiety

I felt I was close to panic
I was aware of dryness of my mouth
I experienced breathing difficulty
I experienced trembling
I was worried about situations in which I might panic
I felt scared without any good reason
I felt my heart beating fast

Stress

I found it hard to wind down
I tended to over react to situations
I felt that I was using a lot of nervous energy
I found myself getting agitated
I found it difficult to relax
I was intolerant of anything that kept me from getting on
I felt that I was rather touchy
Consent & Privacy

Clinical Care Consent

The nature, purpose, risks, and expected outcomes of care will be explained to me before treatment.


I will have the opportunity to ask questions and give or withhold consent for specific procedures.


I understand no guarantees can be made regarding outcomes and that I may withdraw consent at any time.


I understand care will be provided in accordance with professional and infection control standards.

I consent to receive an assessment from the clinical team
I accept Smart Health's Treatment Policy

Communication Preferences

(tick to select and consent)

Appointment Reminders
Receiving results(I acknowledge this may not be secure)

Payment

Payment is required at the time of service.  

The clinic does NOT bulk bill and all accounts are to be paid in full.  On most occasions, a rebate to Medicare can be processed at the time of payment for Medicare eligible services.

We accept payment by cash or credit card.

A 24 hour cancellation notice is required if you are not able to attend your appointment otherwise full payment is required.  This will enable other clients to use the allotted time.  

For non-attendance at an appointment 50% of the appointment fee is required. 

Medicare rebates DO NOT apply in this case of cancellation within 24 hours of an appointment or non-attendance.

If you are running late for your appointment, the appointment length will be shortened so that the next client is not inconvenienced.

Please note that our Doctors do not see WorkCover/RTWSA or Motor Accident cases.

Smart Health reviews consultation fees annually with increases implemented 01 July each year.

I accept Smart Health's Payment Policy
I acknowledge and accept responsibility for payment of all appointments and treatments

Privacy

Smart Health needs to collect information about you for the primary purpose of providing a quality service to you, in order to thoroughly assess, diagnose and provide therapy, we need to collect some personal information from you. This information may be used for:

  • The administrative purpose of running the clinic.

  • Billing either directly through a Third Party such as an insurer or compensation agency.

  • Use within the clinic if discussing or passing your care to another practitioner within the clinic for your ongoing management.

  • In the case of an insurance or compensation claim it may be necessary to disclose and/or collect information that concerns your return to work to an insurer or your employer.

We do not disclose your personal information to overseas recipients.

I have read the information above and understand the purpose of collecting my information. I accept Smart Health's policy regarding the use and disclosure of my information.

To ensure the process of quality treatment provision, information about your assessment results and progress may be given to relevant other service providers, who are involved in your management. These may include your GP, specialists, allied health practitioners, or in the case of compensation claims - insurers, solicitors or employers.

I have read the above information and understand the reasons for the collection of my personal information and the ways in which the information may be used and disclosed and I agree to that use and disclosure.
I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained.
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 it is my choice as to what information I provide an that withholding or falsifying information might act against the best interests of my assessment and therapy progress.
I give permission for the use of an AI scribe program to be used in my consultation to record clinical notes.
Declaration
I confirm the information I have provided is accurate to the best of my knowledge
I consent to the collection and handling of my information in accordance with the Privacy Act 1988 and Smart Health's Privacy Policy
I accept Smart Health's Terms and Conditions of Treatment
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