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
AT LEAST ONE WEEK PRIOR TO YOUR ADMISSION. All information given is treated as strictly
confidential.
(circle)
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:______________
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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

Source: http://randwickdaysurgery.com.au/images/Pre_Admission_Form_Apr13.pdf