Patient Registration

Name(Required)

Prefix First Last

Home Address(Required)

Street Address Suburb Postcode

Occupation

D.O.B

Mobile Phone:(Required)

Home Phone:

Work Phone:

Email:

Emergency contact

Name

First Last

Relationship:

Phone:

Patient Details

Medicare Number:

Reference Number: (number next to your name)

Private Health Insurance Fund Name:

Memebership number:

Overseas/student fund?

Yes

Pension Number:

GP Details

Name

Prefix First Last

Practice Address:

Street Address Suburb Postcode

Questionnaire

How did you hear about Dr Hemrajani?

GP referred

Family / friend reccomended

Internet search

Previous patient

St Vincent’s Hospital specialists list

Other

Other - please specify:

What was the first day of your last period?

Do you have any known allergies? If yes, what are they?

Do you have any significant past medical history?

Yes

If Yes - please specify:

When was your last pap smear taken?

Was it normal?

Yes

Do you smoke?

Yes

If yes, how many cigarettes per day?

Do you drink alcohol?

Yes

If yes, how frequently?

Do you take any recreational drugs?

Yes

If Yes which ones and when:

Do you have any significant family medical history?

Yes

If yes, please give details here:

Do you take any form of supplements (eg Folic Acid, Iron, Elevit, Blackmore pregnancy multi, Vitamin D)?

Do you currently take any medications? If Yes then please list them:

Have you ever been pregnant before?

Yes

If yes, please enter details of your pregnancies on below if you are seeing Dr for management of your current pregnancy.

Year of pregnancy:

Result of pregnancy – (terminated, miscarried, ectopic or live baby)

No of weeks:

Place:

Problems during pregnancy

Problems during labour

Painkillers you had during labour (gas, injection, epidural or none) :

Delivery method (Normal, caesarean, forceps, vaccum):

Sex of baby (eg boy or girl) :

Birthweight of baby:

Name of baby:

Breastfed?

Yes

Hospital:

Are you an infertility patient?

Yes

If yes, please enter partner details below.

Partner Name:

First Last

Partner D.O.B :

Partner Mobile no:

Partner Medicare Number:

Reference number: (number next to name)

Consent

TEST RESULTS

I understand it is my responsibility to organize appointments to discuss test results with the doctor. I understand that this practice doesn’t give results over the phone or email even when they are normal.

CANCELLATION POLICIES

Gynaecology appointments: Please note we require 24 hours’ notice for appointment cancellations. Failure to do so will result in a fee being charged. Initial appointments - $50 Review appointments - $30

Theatre procedures: Please note any cancellations/re-scheduling of theatre procedures may incur cancellation fees for doctor, assistant, anaesthetist, theatre etc.

Signature(Required)

Date(Required)