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Online Assessment
Step 1 – Medical History
Step 2 – Preferences
Step 3 – Imagery
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✆1300759436
ASSESSMENT STEP 1
MEDICAL HISTORY
To begin your assessment, please complete the short medical history form below
First Name
*
Last Name
*
Address
*
Street Address
City/Suburb
*
City/Suburb
State/Territory
*
State/Territory
Post Code
*
Post Code
Phone
*
E-mail
*
Date of Birth
*
DD
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/
MM
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YYYY
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Occupation
Height (cm)
*
Weight (kg)
*
Next of Kin
*
Name
Relationship
Relationship
Phone
*
Phone
Medical History
Joint with Concerning Pain
*
--Select Joint--
Knee
Hip
Shoulder
Elbow
Wrist/Hand
Ankle/Foot
Spine
Which Side(s)?
*
--Select Side--
Left
Right
Both
Not Applicable
Knee Surgery required (If known)
--Select Surgery--
Total Knee Replacement
Partial Knee Replacement
Knee Meniscus Repair
Unsure / Not Certain
Other
Hip Surgery Required (If known)
--Select Surgery--
Total Hip Replacement
Partial Hip Replacement
Unsure / Not Certain
Other
Shoulder Surgery required (If known)
--Select Surgery--
Total Shoulder Replacement (Total arthroplasty)
Partial Shoulder Replacement (Hemiarthroplasty)
Ligament/Tendon Repair
Time since Pain first started
Have you had Medical Imagery taken?
X-Ray
CT Scan
MRI
Ultrasound
Unsure
Surgery (Other)
Describe the surgery (not listed) recommended for your joint condition
Nature of Pain
*
Sharp/Stabbing
Dull/Aching
Referred/Pain Felt Elsewhere
What events led up to this injury/pain?
*
What makes the pain worse?
*
History of treatments which HAVE reduced pain
*
History of treatments which HAVE NOT reduced pain
*
What does this condition prevent you from doing?
*
What do you hope and expect to achieve with treatment?
*
Next
Do you have or have you suffered from:
Allergies: Food, medications etc.
*
Yes
No
Asthma
*
Yes
No
Lung Disease
*
Yes
No
Heart Problems
*
Yes
No
High Blood Pressure
*
Yes
No
Cancer
*
Yes
No
Epilepsy
*
Yes
No
Psychiatric Problems
*
Yes
No
Gastrointestinal Problems
*
Yes
No
Liver Problems
*
Yes
No
Hepatitis A, B or C
*
Yes
No
Renal Problems
*
Yes
No
Kidney Infections
*
Yes
No
Musculoskeletal Problems
*
Yes
No
Osteoporosis
*
Yes
No
Osteoarthritis
*
Yes
No
Rheumatoid Arthritis
*
Yes
No
Blood Disorder
*
Yes
No
Thrombosis
*
Yes
No
Diabetes Type 1 or 2
*
Yes
No
Thyroid Disorder
*
Yes
No
Menopause
*
Yes
No
HIV or AIDS
*
Yes
No
Previous Surgery
*
Yes
No
Are you on any of the following?
Chemotherapy
Anticoagulants
Antibiotics
Steroids
If you answered "Yes" to any of the questions above, please provide more information
Please list any unmentioned medications and supplements you are currently taking (if any)
Name of Medication/Supplement
Reason?
Name of Medication/Supplement
Reason?
Name of Medication/Supplement
Reason?
Agree to terms and conditions?
*
I agree
to World Orthopaedic's
Terms and Conditions
(found in full
here
) and to submitting the following information for use in obtaining medical advice and treatment information from World Orthopaedic's affiliated clinics and/or hospitals in accordance with their
patient information handling policies
.
Message
Submit Assessment
Step 1
Medical History
Step 2
Preferences
Step 3
Imagery
Need Assistance?
Call us
Ph:
1300 759 436
(7 Days, 9am-5pm)
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