Pre-Appointment Questionnaire

Patient Information

First name *

Surname *

Date of Birth *

Gender

Phone Number *

Street Name *

City *

State *

Post Code

Email Address *

Medicare Card Number/ URN *

Third Party Details

Claim Number

Case Manager

Case Manager Contact Number

Case Manager Email

Emergency Contact Information

Emergency contact *

Phone *

Emergency contact’s relationship to you

Social Situation

Who do you live with? Do you have dependants? Who would you class as supportive in your life currently? Are you caring for anyone currently? *

Work Information

Current work status *

EmployedRetiredNot workingLight Duty

What kinds of physical tasks do you have to do in your job?

Health Professionals

Name of regular GP

GP Practice with contact details

Other Doctors currently involved in your care

Other Health Professionals including Allied Health, Alternative Medicine Practitioners involved in your care

Injury and Symptom Details

What was your original injury? (if there was one) *

Date of original injury (if there was one)

Would you like to upload information or scan results in regards to your injury?

Browse

What is the rough date of onset of the above extra bodily protection signs and symptoms?

Treatments

Please list any past medications you have tried for this issue and how you found them

Medications

Please list any medications you are currently taking and how you are finding them

Medications *

Please describe any past treatments for this issue and how you found them

Past treatments *

Please describe any current treatments for this issue and how you are finding them

Current treatments (non medication treatments) *

Please list any supplements you are currently taking

Supplements *

Other Health Issues

What other symptoms are you experiencing in the affected body part? *

What symptoms are you experiencing in other parts of your body? *

What medical issues have you had in the past? *

Please describe all of the medical issues current for you? *

Lifestyle

Do you smoke? *

YesNoI used to smoke

Do you use recreational drugs?

NoI have previously usedI currently use

What exercise do you do and how much? *

Please describe what activities you engage in (currently or would like to return to) that could be described as leisure/hobbies/enjoyable activities *

Please describe what you consume in terms of food and drink on a regular basis *

Consent

I consent to Compassionate Hands for CRPS communicating with other involved health care providers including GP, Specialists and Allied Health in order to co-ordinate care.

Signature

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Date *