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Dr David Manohar
Home
About Me
Areas of Expertise
Information
For Patients
Patient Registration
For Referrers
Home
About Me
Areas of Expertise
Information
For Patients
Patient Registration
For Referrers
Contact & Location
Patient Registration
For Patients
Patient Registration Form
Step
1
of
7
– Patient Details
14%
Your Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First Name
Surname
Phone
*
Email
*
Address
*
Street Address
Address Line 2
City
State
Postcode
Date of Birth
*
Day
Month
Year
Age
*
Country Of Birth
*
Country Of Birth
Australia
——–
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Insurance & Medicare Details
Do you have private health insurance?
*
Yes
No
Name of Insurer
*
Insurer Membership Number
*
Medicare Card Number
*
Your Medicare Reference Number
*
The number next to your name
Medicare Card Expiry Date
*
Month
Year
Is this related to a 3rd party insurance claim
*
Yes
No
Injuries
*
please list
Claim Type
*
Workers Compensation
Other
Insurance Company
*
Claim Number
Date of Injury
Case Manager
Case Manager Email
*
Do you have a Solicitor?
Yes
No
Solicitor
Solicitor Email
Solicitor Phone Number
Referral Details
Referring Doctors Name
*
Referrers Email
Referrers Phone
*
Referrers Address
*
Street Address
Address Line 2
City
State
Postcode
Referral Date
Your GP
Your GPs Name
*
Your GPs Phone
*
Tell us about your pain
Your Gender
*
Male
Female
Where are you experiencing pain?
Clear
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Where are you experiencing pain?
Clear
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Type of sensation
Burning
Stabbing
Ache
Numbness
Pins and Needles
List your pain and problems in order of severity (most severe first)
The following activities may increase, decrease or have n effect on your pain, Please select the ones that best applies to your pain.
Movement
Walking
Bending
Lifting
Reaching
Grasping
Twisting
Distraction (TV, Movie, reading) Urination, Bowel movement
Stress/Tension
Going to work
Everything
Leave blank if they have no effect.
Details of anything else that increases your pain?
Is there anything else that relieves your pain?
How did you get hurt?
Please describe how you got hurt.
What parts of your body hurt immediately after the accident?
Immediately after the injury, where did you go, did you report it and to whom?
What hurt in the week following the accident?
Regarding Work
Did you miss any work?
*
How much work did you miss?
*
How much are you working now?
*
What kind of work do you usually do?
*
Is it any different now?
*
Medication and Other Information
Are you taking any medication?, please list.
Who are the other doctors that you have seen for this problem?
What investigations/x-rays have you had?
What treatment have you had?
*
Physiotherapy
Hydrotherapy
Chiropractic
Tablets
Massage
None of the above
Have you had this type of pain before the injury?
*
Have you had any previous work injury?
Do you have any other medical problems? Please List.
Do you have any allergies? Please List.
How is your sleep?
Why do you not sleep?
How are you coping emotionally?
Health Information Privacy Policy
Medical records containing personal information will be maintained throughout your treatment. These records will contain information including, but not exclusive to, your name, address, date of birth, Medicare number and your referring doctor’s details. During the period of assessment and ongoing management, information of relevance is recorded in clinical notes. These records are stored securely and may be kept for up to seven years following your last consultation. If necessary, for the continuity of your medical care, this information may be shared with other health practitioners involved in your treatment. In certain circumstances there may be a legal obligation to disclose clinical information.
I acknowledge that:
*
Details about my health will be recorded by All Pain Care in a confidential file. This file may be in a scanned or paper-based or digital format.
my consent will apply to this and subsequent consultations, until withdrawn by me in writing.
I consent to allowing All Pain Care to:
*
take a medical history and to collect personal information about me in order to attend to my health needs and for associated administrative purposes;
pass on/discuss relevant medical information about me to my referring doctor and any health care provider to whom I am referred by my consulting doctor;
pass on/discuss relevant medical information about me to insurance or legal representatives (for example insurer, employer, solicitor) in the case of Third Party or Workers’ Compensation matters.
include information about my treatment on my printed receipt to enable me to claim my medical rebate entitlement; request relevant medical information regarding my medical history from other doctors or health care professionals involved in my care; recall me for follow up of medical problems as deemed necessary;
disclose relevant de-identified medical information for research and quality assurance activities to improve individual and community health care and practice management;
Refer for and provide physiotherapy treatment, including documentation and storage of clinical information and discussion of clinical information with other medical and health care providers and legal/compensation/insurance representatives.
I understand that I am not obliged to provide any information requested of me. I also understand that failure to provide this medical practice with all the information it needs may restrict the practice’s ability to provide the quality of health care and treatment that I want;
Note: If you are a guardian this policy is to be read as from the perspective of the patient for whom you are a guardian.
I have filled out this form to the best of my ability and by pressing submit understand this to be by way of electronic signature.
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