Registration Form Dr Serag Youssif

Title

Miss

Mrs

Ms

Mr

Dr

Prof

First Name as on Medicare Card

Last Name as on Medicare Card

Address

Suburb

Postcode

Phone

Home

Work

Mobile

Date of birth

Occupation

Patient Medicare Number

Reference Number

Expiry Date

Email of patient

Spouse / Partner Name

Date of birth

Spouse / Partner Medicare Number

Reference Number

Expiry Date

Spouse / Partner Occupation

Spouse / Partner Mobile

Spouse / Partner email

Next of Kin Name

Mobile

Next of Kin Name address

Pension No:(Aged)

Veterans Affair Gold Card No

Private Health Fund Name

Membership No

No on Card

Hospital cover: Yes No

Level of Cover

Date of joining

Your Doctor Name if different from Referring Doctor

Address

Telephone

Initial consultation: $300 Review Consultation $ 200

Payable on the day by Cash, EFTPOS or Credit Card

Ultrasound Scan: Fee Apply if Required or Requested No Rebate.

Procedure Fee Apply if Needed and Agreed.

Please submit your Medicare Card if you have Medicare during each visit

Signature

Date

Name

Date

When did you have your Last Menstrual Period

Do you have regular menstrual cycles /periods? Yes No

How many days do you bleed

How long are your menstrual cycles

Do you or your partner use Birth Control / Contraception? Yes / No.

• If Yes –circle, highlight or mark one Pill, Mini-Pills, Depoprovera injection, IUD, Mirena, Implanon, Tubal Ligation, Essure, Condom, Safe Period, Withdrawal, Vasectomy

Do you have children? Yes No If Yes how many children do you have?

Number of Babies Born Vaginally / Normally Forceps Vacuum Caesarean Section

Miscarriages No Yes If Yeas How many ?

Ectopic Pregnancy No Yes If Yes Right or left How many?

Cervical Screen Test (Pap Smear): This year Yes If No When?

Have you ever had abnormal smear test? No Yes

When

Treatment

Have you had any operations or procedures? No. If Yes Please list them all with date if you remember

Do you have any medical condition/illness/disease/ disability? No. If Yes Please list them all

Do you currently have, or have you suffered from the following:  Heart problems  Epilepsy  Thrombosis, clotting or DVT

 Stomach problem  bowel problems  High Blood Pressure  Diabetes  Thyroid problems  Lung problems  Depression

 Hepatitis  H.I.V.  Urinary or Bladder problems  Psychiatric problems  Anaemia  Stroke  severe Bleeding at surgery or Birth  Anaesthetic Complication

Do you use Any Medicine/tablets/injections/patches/inhalers/ Pessaries/ Suppositories/ eye drops? No. If Yes Please list all medications

Are you on any blood thinner? No, if Yes Which one

Are you taking weight reducing medications No, If Yes Which one

Are you allergic to any medication, tablet, injection, dressing, skin preparation, latex or anaesthetic? No. If Yes Which one, please list all

Do you have any dietary intolerance?

Smoking No Yes how many per day?

Argileh Nargila Shisha No Yes

Vaping No Yes

Thrombophilia: Personal or strong family history (first-degree relatives) of venous thromboembolism together with one or more of the following: Factor V Leiden mutation, Prothrombin G20210A mutation, deficiency of antithrombin, heparin cofactor II, protein C or protein S, the presence of either lupus inhibitor or anticardiolipin antibodies

Bleeding Tendency: Are you prone to bleeding at surgery or during birth? i.e. Von Willebrand’s

PRIVACY STATEMENT: This medical practice collects information from you for the primary purpose of providing quality healthcare. We ask you to provide us with your personal details and a full medical history so that we can properly assess, diagnose, treat and be proactive in your healthcare needs. We may use the information you provide for administrative purposes in running our medical practice, including billing and compliance with Medicare and Health Insurance Commission requirements. Information may be sent to other practitioners involved in your care. Confidentiality will always be maintained if any information related to your care is used in research, quality assurance or educational purposes.

I consent to the handling of my information by this practice for the purpose set out above. I understand my obligation regarding payment of my account.

Print Name

Signature

Date

Please complete this form prior to appointment and email it to dryoussifs@hotmail.com