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To enable us to organise an appropriate appointment for you we ask that you complete the enclosed Patient Detail Questionnaire and return to our office as soon as possible. If not previously forwarded, please include the following: • X-Ray or Scan Reports (Films are not required at this point) Please bring your films on the day of your appointment The above forms can be mailed, faxed or emailed to our office. Current address: The information received will be reviewed by Dr Albietz and we will contact you by mail within 7 working days with an appointment date and time. Thank you for your understanding and co-operation. If you have any further questions please do not hesitate to contact our office on 07 3721 8600. DATE: ____/____/ ____

Title: Mrs Miss Ms Mr Mast Dr
Family Name: Given Name:
Address:
Date of Birth: ____/____/___ Occupation: Email:
Ph: (h)
Medicare Reference Number (Small Number in front of your name): Dept Of Veteran Affairs No: Exp: / / Gold Card / White Card Health Care Card / Pension No: Are you a member of a Private Health Fund: Health Fund: Membership No: Level of Cover (Please tick): Have you served the 12 month waiting period ACCOUNT PAYMENT DETAILS
Self
Workcover Claim No:

REFERRAL DETAILS
Referring Doctor Name:
Address:
Usual GP (If different from referring doctor)
Address:

NEXT OF KIN DETAILS
Next of Kin:
Address:
Phone:

PATIENT CONSENT
I give permission for you to disclose to any doctor, health authority, allied health provider, rehabilitation provider,
Workcover Insurer and its agents, or other insurer any information about my medical history relevant to my treatment.
Signature:
X-RAYS
QCOS Orthopaedic does not store x-rays / scans for any period of time exceeding twelve months. It is essential
that you keep the scans in your possession at all times.
I hereby understand that the QCOS Orthopaedic will destroy any x-rays or scans left in their possession after twelve
months, without prior notice.
Signature:

Patient Health Questionnaire

1. Do you have a history of:
Please specify:
Deep Vein Thrombosis (DVT) Yes No Do you have a family history of DVT or PE Arthritis (Osteo, Rheumatoid, Gout etc) Yes No 2. Please list any current or previous medical problems.
3. Have you had any previous operations?
Operation
When (Year)
4. Are you taking any of the following medications?
If yes, please discuss with your doctor
• Plavix, Clopidgrel, Wafarin, Aspirin, Cartia 5. Please list all other medications.
Medication: eg Panadol
Dose: eg 1 gram
Frequency: eg 4 per day Route: capsule

6. Please list any allergies
Medication / Substance
Reaction
7. Have you had any previous back/neck complaints:
1.________________________________________________________________________________________________
2.________________________________________________________________________________________________

Do you have a current legal claim regarding this condition?
Are you seeing a Solicitor for this condition?

Please indicate on this diagram where your pain is located.
Mark areas of pain using shading.
Mark areas of tingling or pins and needles with crosses.




Please mark your current level of back pain on the scale below.

0 is no pain and 10 is the worst pain imaginable.
|___|___|___|___|___|___|___|___|___|___|

0 1 2 3 4 5 6 7 8 9 10
Please mark your current level of leg pain on the scale below.

0 is no pain and 10 is the worst pain imaginable.
|___|___|___|___|___|___|___|___|___|___|

0 1 2 3 4 5 6 7 8 9 10


This questionnaire has been designed to give the doctor information about how your back pain has affected your ability
to manage in everyday life. Please answer each section and mark only one box per section that applies best to you.
We realise that you may consider that two of the statements may apply to you, but please only mark the box that
best describes your problem.
Back Pain Questionnaire
Pain Intensity
Standing
I can tolerate the pain without having to use pain killers The pain is bad but I manage without taking pain killers I can stand as long as I want but it gives me extra pain Pain killers give complete relief of pain Pain prevents me from standing more than one hour Pain killers give partial relief of pain Pain prevents me from standing more than 30 minutes Pain killers give very little relief of pain Pain prevents me from standing more than 10 minutes Pain killers have no effect on pain and I do not use them
Personal Care
Sleeping
I can look after myself normally without extra pain I can look after myself normally but it causes extra pain It is painful to look after myself and I am slow and careful Pain interrupts my sleep half of the time I need some help but manage most of my personal care I need help every day in most aspects of personal care I do not get dressed, wash with difficulty and stay in bed Social Life
I can lift heavy objects without extra pain My social life is normal and gives me no extra pain I can lift heavy objects but it gives extra pain My social life is normal but gives me extra pain I can only lift heavy objects if they are on a table Pain restricts more energetic social activities I can only lift light / medium objects if they are on a table Pain has restricted my social life and I go out less often Pain has restricted my social life to home Travelling
I can travel anywhere without extra pain I can walk comfortably but running is painful I can travel anywhere but it causes some pain Pain prevents me from walking more than one hour Pain is bad but I manage to travel over two hours Pain prevents me from walking more than 30 minutes Pain restricts me to trips of less than one hour Pain prevents me from walking more than 10 minutes Pain restricts me to trips of less than 30 minutes I cannot walk more than a few steps at a time Pain prevents me from travelling except to the doctor Employment / Housekeeping
I can sit in any chair as long as I want My normal homemaking/ job activities don’t cause pain I can only sit in a special chair as long as I want I can perform all these activities but do experience pain Pain prevents me from sitting more than one hour I can perform most activities but do experience pain Pain prevents me from sitting more than 30 minutes Pain prevents me from doing anything but light duties Pain prevents me from sitting more than 10 minutes Pain prevents me from doing even light duties Pain prevents me performing any job/ activities at all Office Use Only _______/_______ _________%
Height: (cm)

Weight (kg)
What date did the injury occur?
How did the injury occur?

Have you had any previous treatment with regards to this injury? Eg: Physiotherapy, Chiropractic, Occupational
Therapy, Psychology, Injections, Pain Medication, Acupuncture etc.

If you have had any of the above treatment, when did it commence and how often have you been having
treatment?

Have you seen any other Specialists with regards to this injury?

Have you had any x-rays, CT scans or MRI’s taken with regards to this injury?
Please list the tests that you have had:

Are you currently working?


WorkCover Patients Only
WorkCover Claim No:

WorkCover Claim Manager:

Employer Name:

Employer Phone No:
Before this accident, did you have any condition or injury that affected this part of your body?
Have you had any other previous WorkCover claims?

WorkCover Patients Only
Important Information
It is very important that your WorkCover Medical Certificates are kept up to date at all times. Please request a new
certificate from your doctor at each appointment, if required.
Your consultations will only be paid by WorkCover if they hold a current Medical Certificate.
It is the patient’s responsibility to give a copy of the Medical Certificate to WorkCover and the Employer. This
certificate is also to be given to anyone that is providing treatment eg: Physiotherapist, Chiropractic, Occupational
Therapist, Hand Therapist etc
A current referral must be held by our office at all times.
Medical Certificates will not be issued over the phone.
Signature: Date:

Source: http://www.qcos.net.au/pdfs/albietz-back-appointment.pdf