Medical Questionnaire | Hunter OMS Newcastle

Step 1 of 11

Phone

This field is for validation purposes and should be left unchanged.

Patient Name*

First Name Last Name

Mobile Phone*

Email*

DOB*

Day

Month

Year

Gender*

Height (cm)*

Weight (kg)*

Residential Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Medical History

Have you ever been diagnosed with any of the following conditions?

Heart disease

Diabetes

Anaemia

High blood pressure

Kidney Disease

Osteoporosis

Rheumatic fever

Asthma

Epilepsy

Other prolonged illness

None of these

Please give details...*

Do you have any allergies to any medications or substances?*

Yes

If yes, please tick where appropriate*

Penicillin

Pain killers

Iodine

Anti-inflammatories

Codeine

Latex

Other medication/drug/substance

Please give details...*

Your Reaction To The Medication?*

Rash

Swelling

Vomiting

Other

Please give details...*

Have you had any operations?*

Yes

Please give details...*

Have you or your family had any problems with general anaesthesia?*

Yes

Please give details...*

Have you ever had prolonged bleeding following tooth extraction, cut or injury?*

Yes

Please give details...*

Are you currently under the care of a medical specialist (e.g. cardiologist, endocrinologist, neurologist, rheumatologist)?*

Yes

Please provide their name, specialty, and clinic details.*

Do you or anyone in your biological family have a history of problems or complications with general anaesthesia?*

Yes

Unsure

Have you ever been diagnosed with a rare genetic or inherited condition?*

Yes

Please give details...*

Does anyone in your biological family have a rare genetic or inherited condition?*

Yes

Unsure

Please specify the condition and their relationship to you*

Do you take any of the following medications?

Eliquis

Prolia

Warfarin

Aspirin

Plavix

Any other blood thinning medication

Are you taking any medications or drugs regularly?*

Yes

Please give details...*

Do you use recreational drugs? (eg: cannabis, cocaine, heroin)*

Yes

Do you consume alcohol?*

Yes

How many standard drinks per week?*

Do you smoke or vape?*

Yes

Previous smoker

How many per day?*

If female, might you be pregnant?*

Yes

Unsure

Are there any other health issues you wish to discuss with your surgeon?*

Yes

Please give details...*

Is there anything your surgeon should be aware of that is not on this form?*

Yes

Please give details...*

Medicare Card

Is the patient over 18 years of age?*

Yes

Medicare Card Number*

Patient’s reference no.*

Valid to date*

Day

Month

Year

Under 18 Medicare

Parents Name*

Parents DOB*

Day

Month

Year

Medicare Card number of parent*

Parent’s reference no.*

Valid to date*

Day

Month

Year

Patient's reference no.*

Health Fund details

Do you have a health fund?*

Yes

Health Fund Name*

Membership no.*

Primary cardholder’s name*

Reference no. on card*

Cover*

Hospital only

Hospital & Dental

Extras Only

Patient’s reference no. (if different to primary cardholder)

Concession Card Details

Concession card (Tick all that apply)

DVA

Pension

Health Care

DVA Card no.*

Pension Card no.*

Health Care Card no.*

Workers Compensation

Are you seeing us due to a Work related injury or CTP related injury?'*

Yes

Insurer*

Injury type*

Date of injury*

Day

Month

Year

Claim Number*

Case manager*

Cast Manager Phone*

Case Manager Email*

Next of Kin

Name*

Relationship*

Phone no.*

Dentist details

Name*

Phone no.*

General practitioner details

Name*

Phone no.*

Privacy Policy

AI-Assisted Note Taking

We utilise a note taking tool called Heidi to capture the details of our consultations accurately and efficiently, and the outcomes of your appointments.

Heidi ensures that your surgeon can focus more on your conversation and less on manual note taking, enhancing the quality of care you receive. Your consent is required for us to use this technology during your consultation.

Your information is safeguarded:

✓ All data is de-identified and encrypted to the highest standards

✓ No audio recordings are stored after processing

✓ Information will only be used by the treating Practitioner to deliver your care

✓ It will not be disclosed to those not associated with your treatment without your express consent

✓ Compliant with Australian Privacy Principles, ISO 27001 & SOC 2

✓ Consent is entirely voluntary and will not affect the quality of care you receive

Heidi Note Taking Consent*

Yes, I consent to to the use of Heidi note taking tool during consultation

Clinical History Consent*

Yes, I consent to obtain and release relevant information regarding my clinical history

By submitting this form, I hereby give consent for Dr Benjamin Gupta/Dr Gary Hoffman/Dr Alan Samakeh to obtain and release relevant information regarding my clinical history. This information will only be issued by the treating Practitioner in order to deliver your care to the highest standards.

Patient’s Information

Patient’s Information

Patient Information

Medical History

Medicare Card

Under 18 Medicare

Health Fund details

Concession Card Details

Workers Compensation

Next of Kin

Dentist details

General practitioner details

Privacy Policy

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