Better Growing Bodies

Health Care Clinic

Dr Sahil Vohra

Please complete the Pre-operative assessment below.

Should you have any issues with the form you can contact us via email at info@drsahilvohra.com.au.

Please allow 10 - 15 minutes to complete form. You can save it and return later if you require more time.

Title

First Name *

Middle Name *

Surname *

Home Address *

Street address *

City *

State *

Postcode *

Postal Address if applicable

Street address

City

State

Postcode

Date of Birth *

Gender

Home phone number

Mobile number *

Email Address *

Martial Status *

Emergency Contact Person *

Emergency Contact mobile *

Relationship to patient *

Next of Kin Name *

Next of Kin mobile

Next of Kin Relationship to patient

General Practitioner's Name, Suburb & Phone *

In-Patient Hospital Details

Medicare Number *

Medicare Number for patient *

Medicare Date Expiry *

DVA Number

DVA Cover

Private Health Fund Name

Private Health Fund Number

Operation Details

Surgeon attending operation *

Anaesthetist Doctor's Name is known

General Medicine Specialist Physician

Planned Date of Surgery

Have you had any previous surgery *

YesNo

List of previous operations

History of reactions to anaesthetics *

Yes myselfNoA blood-related family member

Personal information

Who do you live with? *

Any of the following conditions in your medical history *

MRSA infection (Golden staph)PE (Pulmonary Embolism)DVT (Deep vein thrombosis)None

How far can you walk in metres before you become short of breath or pain is too extreme *

History of falls? *

Yes - please provide further detailsNo

List number of falls

Do you have stairs inside or outside your home? *

YesNo

Where are the stairs located and how many?

Please upload any medical discharge summaries

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Smoking status *

Yes I smoke currentlyNo never smokedEx-smoker

If you clicked yes how many cigarettes do you smoke daily?

Do you take illicit drugs? *

Yes-Please provide details belowNo

Drug history if applicable

Do you consume alcohol? *

Yes - please provide detailsNo

How many drinks would you have daily, weekly or I just drink socially

Medical History

Medications *

Allergies/Intolerances *

Do you take any supplements? Please list below *

Details below about your Respiratory conditions.

If Yes, please provide details

History of Cancer?

Yes-please state where and year it was diagnosedNo

Please provide further details if you clicked yes.

Details

Please provide details

If yes, please provide name of specialist

Any past specialist reports? Please upload

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Did you wish to provide any other information relevant for the Doctor? List below

What is your height in cm? *

What is your weight in kg? *

Consent

By signing this form, you are stating that the information you have provided is correct and true to your knowledge. Please understand that providing us with false information can be dangerous to a patient's health. Should your information change, please notify the Doctor as soon as possible.

I consent to patient information being shared when required by law or with other health professionals.

I consent to the assessment attended by Dr Vohra to be reported on and sent to the Surgeon, Anesthetist, (the patient's) GP and the hospital in preparation for my upcoming surgery.

I am responsible for the payment of consultation and treatment fees, including cancellation fees if they occur. (Please allow 24 hours for cancellations or fees may apply).

I consent to Dr Vohra and his staff to access my medical information, reports and results from investigations from any source for my assessment and management.

Medicare consent *

Yes I consent to BGB Health Care Clinic sending my invoice to Medicare for my rebate.No I do not consent, I will pay in full and organise my own rebate with Medicare.

My Health Record consent for the Doctor to access your medical information *

Yes I consent to My Health RecordNo I do not consent

iScribe AI Technology - Dr Vohra uses AI software for note taking-Your data is protected *

Yes I consent to the Doctor using AI software during our consultation (Your information is deleted after completion of his letter).No I do not consentI would like to know more about how my data is stored.

Signature *

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Date *

Name of carer completing this form for patient

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