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Microsoft word - 001a pre-admission form.docx

Clinical staff use only: If PA Assessment by RN was required tick sign_____________Director of Nursing sign___________ This centre is owned and operated by Dr M. Stergoulis, Dr J. Cannon & Dr A. Theodore email: [email protected] Please answer ALL questions, printing clearly, and RETURN THE FORM TO THE DAY SURGERY
All information given is treated as strictly
Mr/Mrs/Ms/Miss/Master/Dr: Surname_______________________ Given Names __________________
Home Address _______________________________________________________________________ _______________________________________________________________________P/code_______ Postal Address (if different from above)_______________________________________P/code_______ Telephone-Home_________________ Business _________________ Mobile ____________________ *Please be advised all patients over the age of 55yrs will require pre-anaesthetic testing, this includes Full Blood
Count, BSL & ECG (speak to your dentist/RDS for further information)*
*Age _______Date of Birth ______________Sex: M F Occupation: _____________________ Medicare No:__________________________ Valid to: ___________ Ref:_______ Veterans Affairs No: ________________Pensioner Pharmaceutical Benefits No. __________________ Do you have private health insurance - hospital cover? Yes
Name of member _____________________ Have you had membership for >12 months: Y / N Next of Kin: Name __________________________________ Tel. No. ________________________
Address: ___________________________________________________________________________ Relationship to patient: _______________________________________________________________ Date of Admission: ___________________________________ Proposed treatment:____________________________________ ( check with your dentist if unsure) Name of admitting Dr/Dentist __________________________________________________________ Is this your first admission to Randwick Day Surgery? Surname:____________________ Given Names:_______________________ dob:______________
The following information is required by the NSW Health Department for statistical purposes: *Country of birth: ________________________ Language spoken at home_____________________ *Are you of Aboriginal or Torres Strait Islander origin: Y, Aboriginal Y, TSI Y, both A&TSI No
*Marital status: Married/defacto
Never married (single) Widowed Divorced Permanently separated Not known
*Have you been admitted to hospital within the last 28 days: No
MEDICAL HISTORY: To be completed by the patient before admission.
Have you had any previous operations or serious illnesses? If yes please detail___________________________________________________________________________________ Have you had any reactions or problems with previous anaesthetics? ___________________________________________________________________________________________________ Do you have an Advanced Health Care Directive Are you allergic to any foods, drugs, complimentary medicines or dressings? If yes please detail______________________________________________________________________________________ Previous Anaphylaxis?_______________________________________________ No Yes Are you being treated for any other medical condition? If yes please detail______________________________________________________________________________________ Please list all medications you are currently taking, including herbal medications such as Fish
Oil, Echinacea, Gingko, St. Johns Wart, Ginger or Garlic tablets._________________________ ______________________________________________________________________________ Do you suffer from any of the following? Please circle your answer Name of General Practitioner: ______________________________________________ Address: _____________________________________________________Tel No:_________________________ * If you do not have a GP or details unknown please tick
Randwick Day Surgery is owned in equal shares and operated by Dr. M. Stergoulis, Dr. J. Cannon, Dr. A. Theodore Standard Forms - 001A Pre-Admission Form Revision 12 23 April 2013


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Kssm/275/09 6/7/2009

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