{"id":3169,"date":"2022-10-24T00:02:47","date_gmt":"2022-10-24T00:02:47","guid":{"rendered":"https:\/\/pclscoffsharbour.com.au\/?page_id=3169"},"modified":"2022-10-24T03:55:32","modified_gmt":"2022-10-24T03:55:32","slug":"test","status":"publish","type":"page","link":"https:\/\/pclscoffsharbour.com.au\/Patient-Details-2022","title":{"rendered":"Patient Details Form"},"content":{"rendered":"

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Fill out our patient details form online below<\/h2>\n

Or Download our patient details form in pdf format here<\/a><\/h5>\n<\/div>\n\t\t<\/div><\/div>
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Personal Details<\/h4>\n
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Date of birth*
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Next of Kin<\/h4>\n
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Date of birth (if parent)
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Referrer Details<\/h4>\n
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Medicare \/ Health Fund Details \/ DVA (Veterans Affairs)<\/h4>\n
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Membership over 12 months
Yes<\/span><\/label><\/span>No<\/span><\/label><\/span><\/span><\/span><\/p>\n
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Fund excess
Yes<\/span><\/label><\/span>No<\/span><\/label><\/span><\/span><\/span><\/p>\n<\/div>\n
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Gold<\/span><\/label><\/span>White<\/span><\/label><\/span><\/span><\/span><\/p>\n<\/div>\n<\/div>\n
Health Questions<\/h4>\n
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Could you be pregnant?
Yes<\/span><\/label><\/span>No<\/span><\/label><\/span><\/span><\/span><\/p>\n<\/div>\n
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Do you use Contraceptives?
Yes<\/span><\/label><\/span>No<\/span><\/label><\/span><\/span><\/span><\/p>\n<\/div>\n
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Do you smoke?
Yes<\/span><\/label><\/span>No<\/span><\/label><\/span>Socially<\/span><\/label><\/span><\/span><\/span><\/p>\n<\/div>\n<\/div>\n
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In the past 6 months, have you had the following?:
Blood Tests<\/span><\/label><\/span>Specialist Appointment<\/span><\/label><\/span>Major health problems<\/span><\/label><\/span>Hospital Admission<\/span><\/label><\/span><\/span><\/span><\/p>\n<\/div>\n
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If you selected that you did have a specialist appointment in the last 6 months, please tell us the reason:
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Have you had any previous surgery?
<\/textarea><\/span><\/p>\n<\/div>\n<div class=\"col-sm-12\">\n<p>Do you have any Prostheses? (joint replacements\/implants)<br><span class=\"wpcf7-form-control-wrap\" data-name=\"prostheses\"><textarea name=\"prostheses\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\"><\/textarea><\/span><\/p>\n<\/div>\n<div class=\"col-sm-12\">\n<p>Have you had Cardiac Stenting \/ Valve or Bypass Surgery?<br><span class=\"wpcf7-form-control-wrap\" data-name=\"cardiac-stenting\"><input type=\"text\" name=\"cardiac-stenting\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/p>\n<\/div>\n<div class=\"col-sm-12\">\n<p>Do you have a Pacemaker?<br><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-898\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-898\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-898\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/p>\n<\/div>\n<div class=\"col-sm-12\">\n<p>Are you on blood thinning medication?<br><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-899\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-899\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-899\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/p>\n<\/div>\n<div class=\"col-sm-12\">\n<p>If yes, did a GP or Specialist prescribe it?<br><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-890\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-890\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-890\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/p>\n<\/div>\n<div class=\"col-sm-12\">\n<p>Do you take Cortisone Tablets \/ Injections or Anti-inflammatory Drugs?<br><span class=\"wpcf7-form-control-wrap\" data-name=\"cortisone\"><input type=\"text\" name=\"cortisone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/p>\n<\/div>\n<div class=\"col-sm-12\">\n<p>Do you have Hypertension?<br><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-891\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-891\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-891\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/p>\n<\/div>\n<div class=\"col-sm-12\">\n<p>Do you have Diabetes?<br><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-892\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-892\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-892\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/p>\n<\/div>\n<div class=\"col-sm-12\">\n<p>If so, which type?<br><span class=\"wpcf7-form-control-wrap\" data-name=\"diabetes-type\"><input type=\"text\" name=\"diabetes-type\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/p>\n<\/div>\n<hr>\n<div class=\"col-sm-12\">\n<p>Do you have Thyroid issues?<br><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-893\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-893\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-893\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/p>\n<\/div>\n<div class=\"col-sm-12\">\n<p>Do you have any Allergies?* (Food\/Medication\/Tapes\/Non-prescription drugs)<br><span class=\"wpcf7-form-control-wrap\" data-name=\"diabetes-type\"><input type=\"text\" name=\"diabetes-type\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/p>\n<\/div>\n<div class=\"col-sm-12\">\n<p>Have you had Covid Vaccinations?<br><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-894\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-894\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-894\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/p>\n<\/div>\n<div class=\"col-sm-12\">\n<p>Have you been infected with Covid in the past 4 \u2013 6 weeks?<br><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-895\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-895\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-895\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/p>\n<\/div>\n<div class=\"col-sm-12\">\n<p>If yes, on what date date? <br><span class=\"wpcf7-form-control-wrap\" data-name=\"covid-date\"><input type=\"text\" name=\"covid-date\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/p>\n<\/div>\n<div class=\"col-sm-12\"><\/div>\n<div class=\"col-sm-12\"><\/div>\n<\/div>\n<p>Are you aware you must have someone to stay with you for 24hrs following surgery?<br><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-896\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-896\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-896\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/p>\n<p>Are you aware that you are not allowed to drive for at least 24 hours?<br><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-897\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-897\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-897\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/p>\n<hr>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"pdf-hear\"><select name=\"pdf-hear\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\">How did you hear about us?<\/option><option value=\"Google\">Google<\/option><option value=\"Facebook Ads\">Facebook Ads<\/option><option value=\"Newsletter\">Newsletter<\/option><option value=\"Friends \/ Colleague\">Friends \/ Colleague<\/option><option value=\"Others\">Others<\/option><\/select><\/span><\/p>\n<h3>Consent<\/h3>\n<h4>RECORDING OF CONSULTATIONS<\/h4>\n<p>As part of your visit with us Dr Arianayagam will record his consultation. This is then stored in your consultation notes as<br \/>\nan MP3 file.<\/p>\n<p>I agree to my consultation being recorded<br><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-918\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-918\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-918\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/p>\n<h4>PHYSICAL EXAMINATION<\/h4>\n<p>If you are consulting with Dr Arianayagam regarding any part of your body that is covered by clothing, you may be asked<br \/>\nto undress. For your privacy, you will offered a dignity sheet to use during the examination. Dr Arianayagam will ask that one of his staff accompany him during the examination, for both your protection as well as his own. Pre-operative photo\u2019s may also be taken during this examination.<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-919\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-919\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-919\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span> I consent to an examination being undertaken, which may involve partial or full removal of my clothing.<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-900\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-900\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-900\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span> I consent to pre-operative photographs being taken, which may involve partial or full removal of my clothing<\/p>\n<p><b>Dr Arianayagam records his consultations to assist with record keeping. Your signature below confirms your consent and that all information provided on this form is correct. If you have any concerns, please speak with the reception staff.<\/b><\/p>\n<h4>Please type your full name below as well as sign<\/h4>\n<div class=\"row\">\n<div class=\"col-sm-6\">Print your name here:<br><span class=\"wpcf7-form-control-wrap\" data-name=\"name-sig\"><input type=\"text\" name=\"name-sig\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/div>\n<div class=\"col-sm-6\">Sign your name here:<br><div class=\"dscf7_signature\">\n\t\t\t<div class=\"dscf7_signature_inner\">\n\t\t\t\t<canvas id=\"digital_signature-pad_signature-252\" name=\"signature-252\" class=\"digital_signature-pad\" color=\"#000000\" backcolor=\"#ededed\" width=\"450\" height=\"200\"><\/canvas>\n\t\t\t\t<input class=\"clearButton\" type=\"button\" value=\"+\">\n\t\t\t<\/div>\n\t\t\t<span class=\"wpcf7-form-control-wrap signature-252\">\n\t\t\t\t<input type=\"hidden\" name=\"signature-252\" value=\"\" class=\"wpcf7-form-control wpcf7-signature wpcf7-validates-as-requiredwpcf7-validates-as-signature sigdscf7-signature\"\/>\n\t\t\t\t<input type=\"hidden\" name=\"signature-252-attachment\" value=\"\" class=\"wpcf7_input_signature-252_attachment\"\/>\n\t\t\t\t<input type=\"hidden\" name=\"signature-252-inline\" value=\"\" class=\"wpcf7_input_signature-252_inline\"\/>\n\t\t\t<\/span>\n\t\t<\/div><\/div>\n<\/div>\n<p><input type=\"submit\" value=\"Submit\" class=\"wpcf7-form-control has-spinner wpcf7-submit\" \/><\/p>\n<p style=\"display: none !important;\"><label>Δ<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"87\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div><p style=\"display: none !important\"><span class=\"wpcf7-form-control-wrap referer-page\"><input type=\"hidden\" name=\"referer-page\" value=\"https:\/\/pclscoffsharbour.com.au\/Patient-Details-2022\" data-value=\"https:\/\/pclscoffsharbour.com.au\/Patient-Details-2022\" class=\"wpcf7-form-control wpcf7-text referer-page\" aria-invalid=\"false\"><\/span><\/p>\n<\/form><\/div>\n<\/div>\n<\/div><\/div><\/div><\/div><\/div><\/div>","protected":false},"excerpt":{"rendered":"<p>Fill out our patient details form online below Or Download our patient details form in pdf format here<\/p>\n","protected":false},"author":4,"featured_media":2952,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"yoast_head":"\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/pclscoffsharbour.com.au\/Patient-Details-2022\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Patient Details Form - 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