Patient Registration Form

PATIENT DETAILS

First Name

Last Name

Preferred Name

Date of Birth

Gender Identity

FemaleMaleOtherPrefer not to say

English is a Second Language

YesNo

Ethnicity

ATSI

AboriginalTorres Strait IslanderNone of the Above

PATIENT CONTACT DETAILS

Home Phone

Mobile Phone

Work Phone

Email

Address

Postcode

City / Suburb

State

EMERGENCY CONTACT DETAILS

Name

Address

Postcode

City / Suburb

State

Home Phone

Mobile Phone

Email

Work Phone

NEXT OF KIN CONTACT DETAILS

Is the next of Kin the same as your emergency (if yes, you do not need to fill this section)

YesNo

Next of Kin - Name

Next of kin - Mobile Phone

REGULAR/REFERRING DOCTOR

Regular GP (if not a patient at Winmalee Medical Centre

Regular GP Contact Details

MEDICARE

Medicare Card No.

Expiry

Ref. No.

PENSION / HCC/DVA Card

Do you have an aged pension card, healthcare card or a DVA card

YesNo

Card Number

Expiry(mm/yyyy)

Card Type

HCCPension

DVA Card Type

GoldWhiteOrange

DVA Number and Expiry

Health Profile Questionnaire

Current Medications

Please list current/past Medical Conditions incl. DVT, Cancers, Diabetes, Hypertension, Cardiovascular Disease/Stroke, Migraine, Gallstones/Liver Disease

Please list any previous surgeries (including for Endometriosis)

Current or Former Smoker (including Vaping)

Alcohol - how many per day or week

Allergies

Family History incl. Cancers, Diabetes, Cardiovascular/Stroke

Which condition/s are you seeking assistance for

Endometriosis - Please complete below Endometriosis/Pelvic Pain QuestionnairePelvic Pain - Please complete below Endometriosis/Pelvic Pain QuestionnairePeri-Menopause - Please complete Menopause Symptom ScoreMenopause - Please complete Menopause Symptom Score

ENDOMETRIOSIS/PELVIC PAIN QUESTIONNAIRE

Brief outline of Endometriosis/Pelvic Pain Symptoms

List of medications prescribed currently or previously in relation to Endometriosis and/or Pelvic Pain

Brief outline of medications or other treatments trialed for Endometriosis/Pelvic Pain

During the last 4 weeks how often, due to your endometriosis or pelvic pain have you:

In the last 4 weeks how often due to your endometriosis or pelvic pain have you:

PERI-MENOPAUSE/MENOPAUSE QUESTIONNAIRE

Brief outline of medications or other treatments currently or previously prescribed in relation to Peri-Menopause and/or Menopause

Brief outline of Peri-Menopausal and/or Menopause symptoms

In the last 4 weeks have you experienced any of the following:

Hot Flushes/Sweating

NeverRarelyOftenAlways

Light Headed feelings

NeverRarelyOftenAlways

Headaches

NeverRarelyOftenAlways

Brain Fog, Difficulty Concentrating and or Forgetfulness

NeverRarelyOftenAlways

Difficulty sleeping

NeverRarelyOftenAlways

Irritability

NeverRarelyOftenAlways

Mood changes (feeling unhappy or depressed)

NeverRarelyOftenAlways

Anxiety

NeverRarelyOftenAlways

Heart beating quickly or stronger than usual

NeverRarelyOftenAlways

In the last 4 weeks have you suffered from the following:

Muscle and joint pain

NeverRarelyOftenAlways

Unusually dry skin

NeverRarelyOftenAlways

Irregular periods

NeverRarelyOftenAlways

Increased facial hair

NeverRarelyOftenAlways

Dry vagina

NeverRarelyOftenAlways

Decreased sexual desire

NeverRarelyOftenAlways

Uncomfortable or painful intercourse

NeverRarelyOftenAlways

Urinary problems

NeverRarelyOftenAlways

Unexpected weight gain?

YesNo

Fee Structure

Nurse Navigator Consultation - No Charge

GP Consultation - Initial 45 minutes $225.00 with $99.90 out of pocket

GP Consultation - Follow Up 30 minutes $180.00 with $95.10 out of pocket

If you are under 16, a Health Care Card Holder or Commonwealth Pension Card Holder there will be a reduced fee. Please speak to our reception staff and they will advise.

Data Collection & Privacy Statement

The Endometriosis, Pelvic Pain, Peri-Menopause & Menopause Clinic is supported by the Commonwealth Government. As part of their support we are required to collect de-identified data regarding service provision and patient demographics and outcomes.

As a service provider in the Nepean Blue Mountains Primary Health Network (NBMPHN) we are required to have appropriate controls to protect your personal information and use your personal information for authorised purposes only as per the Privacy Act 1988 (Cth), Health Records Act and Australian Privacy Principals.

Winmalee Medical Centre will collect your information via Snapform (a secure online questionnaire platform) and store your information on Best Practice (Winmalee Medical Centre's clinical software). A copy of Best Practice Privacy Policy can be located at: https://bpsoftware.net/privacy-policy/ and Snapform: https://snapforms.com.au/privacy-policy/.

A copy of Winmalee Medical Centre privacy policy is available by contacting 02 4754 1666.

SIGNATURE

I confirm and acknowledge that I have read the above information and my details provided are true, complete and accurate. *

Patient/ Guardian Signature

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