Re:
Patient Demographics.Full Name
Next of Kin:
Patient Demographics.NOK Name
Preferred Name:
Patient Demographics.First Name
Next of Kin Phone:
Patient Demographics.NOK Mobile Phone
Date of Birth:
Patient Demographics.DOB
Next of Kin Relationship:
Patient Demographics.NOK Relationship
Age:
Patient Demographics.Age
Sex:
Patient Demographics.Gender
IHI:
Patient Demographics.IHI Number
Address:
Patient Demographics.Address
Postal Address:
Patient Demographics.Mailing Address
Phone (Home):
Patient Demographics.Phone (Home)
Phone (Work):
Patient Demographics.Phone (Work)
Phone (Mobile):
Patient Demographics.Phone (Mobile)
Email:
Patient Demographics.E-mail
Aboriginal and Torres Strait Islander status:
ATSI Status?
Ethnicity
Ethnicity
Is the patient of refugee background?
Refugee status
If yes, please provide relevant details:
Refugee details
Interpreter Required:
Interpreter required
Preferred Language:
Preferred language
If the client is a paediatric patient, are they under the care of the Department of Child Safety?
Under DoCs care?
Caseworker Details (if applicable):
Case worker details
Does patient consent to email or SMS Contact from West Moreton Health?
Consent to contact
Medicare Number:
Patient Demographics.Medicare Number
Medicare expiry:
Patient Demographics.Medicare Expiry Date
Medicare Reference number:
Patient Demographics.Reference Number
DVA Number:
Patient Demographics.DVA Number
Patient Demographics.DVA Expiry Date
Pension number:
Patient Demographics.Pension Number
Private Health Insurance:
Patient Demographics.Health Fund Name
Private Health Insurance fund number:
Patient Demographics.Health Fund Member Number
Family and Social Clinical History |
Relevant Social History:
Clinical Details.Social History
Relevant Family History:
Clinical Details.Family History
Current and Past Clinical History |
History of Current Conditions:
Clinical Details.Past History
Medication List:
Clinical Details.Medications - Current Regular (with comments)
Allergies/Adverse Events:
Clinical Details.Allergies With Comments
Smoking Status:
Clinical Details.Smoking
Alcohol Consumption:
Clinical Details.Alcohol
Observations, Investigations and Progress Notes |
Height, Weight & BMI:
Clinical Details.Selected Most Recent Measures
Recent Investigations:
Clinical Details.Result List (Selected)
Patient Notes:
Clinical Details.Todays Notes
Electronic Verification and Signature |
Treating Doctor.Name
Treating Doctor.Qualifications
Treating Doctor.Provider Number
Miscellaneous.Date