New Patient Form - Dr Sahil Vohra's Rooms

New Patient Medical Assessment Form

Dr Sahil Vohra

Better Growing Bodies

Health Care Clinic

Please allow 10-15 minutes to complete this form.

You can save and return later if you require more time.

If you have any issues with the form, please email us at info @drsahilvohra.com.au

We look forward to seeing you at your appointment.

Title

First Name *

Middle Name

Last Name *

Date Of Birth *

Occupation *

Email Address

Home Address *

Street address *

City *

State *

Postcode *

Postal Address if applicable

Martial Status *

Birth Gender

Identify as

Do you consent to SMS messaging? *

YesNo

Please complete below *

Aboriginal Torres Strait IslanderAustralian - Non IndigenousBoth Aboriginal & Torres Strait Islander

Medical Information

Medicare Number *

Medicare Line Number for Patient *

Medicare Expiry Date *

DVA Number

DVA cover

DVA colour card

GoldWhiteOrange

Private Health Fund

Health Fund Number

Commonwealth Benefit

Do you receive NDIS?

YesNo

My Health Record - Do you consent to information being shared on your 'My Health Record'? *

YesNo

If you know your My Health Record number please place it here.

Emergency Contact Name and Number *

Next of KinIf the same as Emergency contact then write as above

NOK phone number & relationship to patient

General Practitioner's (GP) Name, phone number and suburb of practice *

Usual Pharmacy's name, phone number and suburbTo be able to send scripts through if required.

Medications *Name of Medications, dosing and timing.

Supplements?

Allergies or Intolerances *

Please list Specialist's Name and location

Please upload any relevant medical specialist letters or files

Browse

Allied Health ServicesPlease list any Allied Health professionals you currently visit e.g Speech Therapist or Occupations Therapist etc.

What is your reason for visiting with the Doctor today *

Do you have any difficulties with your hearing?

YesNoWears hearing aids

Do you wear glasses *

Yes- For readingYes- Long distancesNo

How would you describe your general overall health?

PoorFairGoodExcellent

Are you pregnant

YesNo

What is your current weight in Kg? *

What is your height in CM? *

COVID 19 Vaccination Status? *

Both COVID vaccinesBoosterHave Not had any COVID vaccinations

Do you drink Alcohol? *

YesNo

How much would you drink daily/weekly

Alcohol consumption

Do you smoke?

YesNoEx-smoker

How many?If answered yes, how many cigarettes do you smoke? If you're an ex-smoker, when did you quit?

Do you take Recreational drugs? If yes please list

Do you exercise? If yes please list type of activity. *

YesNo

Type of Exercise

Do you sleep well at night? *

Number of hours of sleep on average each night?

Other

If your parents have passed what did they pass away from?Providing details about your parent's health can provide the Doctor with valuable information.

Describe your pain level at the moment *

No painSlight painEveryday pain but can manage daily tasksExtreme pain, unable to attend daily activities

Any other relevant information you need to add for the Doctor?

Medicare consent *

Consent for Medicare billing through EclipseDo not consent to Medicare billing-will pay privately

iScribe AI Technology-Dr Vohra uses AI based technology for note taking. It is secure and your data is protected. *

Yes I am happy for the Doctor to use this software ( your iScribe data is deleted after Doctor has completed his letter.)No I do not consentI would like more information on how my data is used.

BGB Health Care Clinic may charge an out of pocket 'Gap' payment. By signing this form you are consenting to informed financial consent. The Gap fee is not covered by your private health fund. Medicare rebate will be applied and a portion of the payment will be refunded back into your bank account linked with Medicare. Should you have any questions about payments please contact us via email on info@drsahilvohra.com.au

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