NEW PATIENT FORM FOR PROFESSOR BINDRA
Please take a few minutes to complete this form. Completing all sections will help tailor treatment to your needs.
NAME: ____________________________________________________________________________
DATE OF BIRTH: ___________________ AGE: _________ GENDER ( M / F ): ____________________
NAME OF G.P. OR REFERRING DOCTOR: _________________________________________________
WHO SHOULD WE SEND A REPORT OF TODAY’S VISIT TO: ___________________________________
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HEALTH COVER (please circle): Self pay DVA Workcover Insurance:______________________
HANDEDNESS (Left, right or ambidextrous): ______________________________________________
OCCUPATION AND DESCRIPTION: (Please describe what you do with your hands at work: e.g. keyboard work, writing, cleaning, lifting weights, drill use etc)____________________________
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HOBBIES: (E.g. woodwork, playing guitar, painting)_________________________________________
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WHY ARE YOU SEEING PROF BINDRA TODAY: (Please list your problems and duration)
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ARE YOUR PROBLEMS THE RESULT OF AN INJURY AT WORK/ACCIDENT: (Y or N) _________________
If Yes, please list date of injury and details of incident: ______________________________________
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MEDICAL HISTORY
Do you have any medical problems (e.g high blood pressure, diabetes, depression, hepatitis):
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Are you under the care of any other specialists:___________________________________________
Please list your current medications: ____________________________________________________
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Do you take any blood thinners such as Warfarin (Daktarin), Aspirin or Clopidogrel:______________
Previous surgical procedures and year performed: _________________________________________
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Have you had any special tests for your condition (xrays, scans, nerve tests): Yes/No
If yes, where and when: ______________________________________________________________
Have you had any previous treatment for your condition (therapy, splints, injections):____________
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ALLERGIES: Please list any drug allergies:_________________________________________________ __________________________________________________________________________________
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FAMILY HISTORY
Who lives at home with you: __________________________________________________________
Do you have a history of any of the following in your family: Osteoarthritis, Rheumatoid arthritis, Psoriasis, Dupuytren’s disease, Diabetes, Kidney disease, nerve problems: _____________________
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SOCIAL HISTORY
Are you a smoker: ______________________ How many packs/day: ________________________
For how many years:____________________
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Do you drink alcohol (Y/N): _______________ How many drinks/week: ______________________
PAIN SCALE: Please circle the number that best matches your pain today:
Please mark the location and type of pain on the drawings below:
This form has been completed to the best of my knowledge:
Signed:________________________________ Date:_______________________
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Please print name:_______________________
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