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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