Patient Registration | Dr Julia Crawford

Patient Type

Adult Child

Postal Address (If different from aside)

Emergency Contact Name

Referring Doctor (If different from above)

Medicare & Healthcare Fund

Do you have a Medicare Card?

Yes No

Do you have a Health Fund?

Yes No

Have you been admitted to hospital in the last twelve months?

Yes No

Should we contribute your medical information to www.MyHealthRecord.gov.au?

Yes No

NEW PATIENT QUESTIONNAIRE

NEW PATIENT PAEDIATRIC QUESTIONNAIRE

What problem/s brought you here?

What problem/s is your child experiencing?

History of present illness

Please describe the location of your problem:

Please describe the location of your child’s problem:

How long have the symptoms been present (months/years)

Do you have any drug/medication allergies?

Yes No

If Yes, please list below:

Does your child have any drug/medication allergies?

Yes No

If Yes, please list below:

List any MEDICAL problems (diabetes, cancer, infections, etc) that you have had in the past, including the dates, if possible:

List any MEDICAL problems (diabetes, cancer, infections, etc) your child has had in the past, including the dates, if possible

List any MEDICAL problems (diabetes, cancer, infections, etc)
that you have had in the past, including the dates, if possible:

List any SURGERIES that you have had in the past, including dates, if possible:

List any SURGERIES that your child has had in the past, including dates, if possible:

List any SURGERIES that you have had in the past, including the dates, if possible:

Do you have asthma?

Yes No

Does your child have asthma?

Yes No

Do you use Inhalers?

Regular use Intermittent only I don't use

Inhalers usage?

Regular use Intermittent only I don't use

Do any diseases or cancers run in your family? Please list:

Additional Specialists (Audiologist, Physiotherapist, Endocrinologist, etc)

Additional Specialists (Pediatrician, Audiologist, Speech therapist, Respiratory, Endocrinologist, etc)

Does your workplace require:

Noise/hearing precautions?

Yes No

Mask/breathing protection?

Yes No

Use of smell?

Yes No

Heavy vocal/voice use?

Yes No

Have you ever smoked?

Yes No

Smoked within 12months?

Yes No

Ex-smoker (>12mths)?

Yes No

The age you started smoking(y/o)

How many (cigarettes)/day?

Do you drink alcohol?

Yes No

How many (drinks) /day?

How many alcohol free days/week?

Do you use recreational drugs?

Yes No

Any intranasal use?

Yes No

Are immunisations up to date

Yes No

Does your child snore?

Yes No

Does your child have speech/language delays?

Yes No

Have behavioral issues?

Yes No

Guardian/Parent Name

PERMISSION TO COLLECT AND STORE INFORMATION

We need to collect and store some information about you:
To help us provide good and safe treatment and to provide Government bodies with information to which they are legally entitled. These records will contain information including, but not limited to, your name, address, date of birth, Medicare number, referring doctor’s details and clinical imaging and records. Your medical information is also used, in an unidentifiable way, for auditing, research and education purposes.

We undertake only to collect information which is appropriate to your total care and to only use the information for its intended purpose. Your medical records are stored securely and can only be accessed by authorised staff. We are required to keep your records for up to seven years following your last consultation. If necessary, for the continuity of your medical care, this information may be shared with other health practitioners involved in your treatment. In certain circumstances there may be a legal obligation to disclose clinical information, for example to Government bodies. A full copy of our privacy policy is available on request.

Attach your referral form or any files you want to share here.

File types accepted are PDF, PNG, JPG. Upload file size limit is 4mb

“By clicking on the ‘SEND’ button below, I consent to my data being collected and stored as per Dr Crawford's Privacy Policy. Your data will be kept securely and protected.”

Dr Julia Crawford is a highly trained ENT surgeon treating all general and paediatric conditions, head and neck conditions, snoring and OSA.

EXPERTISE, EXPERIENCE, EXCELLENCE

(02) 8319 9434

SNORING & OSA

Conditions

Treatments

HEAD & NECK

Conditions

Treatments

GENERAL ENT

Conditions

Treatments

Patient Information Registration

ALL SECTIONS OF THIS FORM MUST BE COMPLETED, THANK YOU.

Emergency Contact

GP & Referrer

Medicare & Healthcare Fund

NEW PATIENT QUESTIONNAIRE

NEW PATIENT PAEDIATRIC QUESTIONNAIRE

History of present illness

Current Medications

Social History

Immunisation track

Social History

PERMISSION TO COLLECT AND STORE INFORMATION

Attach your referral form or any files you want to share here.

Quick Links

Conditions & Treatments

Practice Information

Location