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Patient Health Questionnaire - Please Tick Request for Surgical Operation, Procedure and / or Medical Treatment lIST Your

Request for Surgical Operation, Procedure and / or Medical Treatment lIST Your curreNT MeDIcATIoNS
Do you have an advance care directive and/or treatment-limiting orders?............................................................................................... Yes No Include all tablets, capsules, puffers, patches, insulin, eye drops.
If Yes, please bring with you and advise nursing staff. ADMITTING DOCTOR SURNAME CHRISTIAN NAMES
Consult your GP or surgeon if you are unsure of any details. 63 Victoria Street,
Bring all your current medications to hospital in their original package. Ashfield NSW 2131
ANAeSTHeTIc HISTorY ADDRESS
PATIENT HISTORY/Summary of Physical Exam
Telephone (02) 9797 0555
Have you or any family member had a problem with an anaesthetic previously? .......................................................................................................... Yes No Medication Strength Route Dose Frequency
1. Healthy Patient POSTCODE ABN 97 094 662 914 ACN 094 662 914 Facsimile (02) 9798 7555
Have you or a member of your family had special problems with anaesthetics? ............................................................................................................ Yes No 2. Mild Systematic Disease no functional limitations PHONE D.O.B SEX
If Yes, please comment ............................................................................................................................................................................................................................ 3. Severe Disease with definite functional limitations MALE FEMALE
4. Severe Disease that is a constant threat to life DATE OF ADMISSION OPERATION DATE ESTIMATED STAY

AllergIeS Other comments: ............/.........../............. ............/.........../............. A Total Quality Management Facility


Do you have any allergies or sensitivities?.......Yes No Known Latex Allergy?.......Yes No LA GA Neurolept
Relevant HEALTH FUND MEMBERSHIP NUMBER
Do you have any food allergies?.......Yes No Special diet requirements....................................................................................................................................... Infections MRSA VRE Hep B or C HIV
If Yes, please provide details, including allergies to any medications, tapes, lotions, foods etc. .................................................................................................................
Known Allergies: ........................................................................................................................................................................................................
PRE-ADMISSION FORMS
.................................................................................................................................................................................................................................................................

Welcome!
Provisional Diagnosis: ................................................................................................................................................................................................
Other Conditions Present/History of Complications / Aspirin Non-Steroidal Antiflammatory
crueTZFelDT JAKoB DISeASe (cJD): (All patients must complete these questions)
.................................................................................................................................................................................................................................
Did you have a dura mater graft between 1972 and 1989? ........................................................................................................................................... Yes No
Proposed Operation/Treatment:.................................................................................................................................................................................
Do you have a history of 2 or more relatives with CJD or other unspecified progressive neurological disorder? ............................................................. Yes No The management and nurses of The Sydney Private Hospital will strive to make your stay
.................................................................................................................................................................................................................................
Did you receive human pituitary hormones (growth hormones, gonadotophins) prior to 1985? ...................................................................................... Yes No with us as comfortable and pleasant as possible.
.............................................................................................................................................................. Item No. (if known) ..................................
Have you suffered from a recent, progressive dementia the cause of which has not been identified? ............................................................................ Yes No
Prostheses Required: Yes No Prostheses Informed Financial Consent given: Yes No We work as a team and your care, welfare and comfort are our main concern.
Have you been involved in a look-back for CJD or received an In Medical Confidence letter notifying you of a potential exposure to CJD? .............. Yes No
Specific Pre-Operative Instructions (incl Instrumentation) : ........................................................................................................... Chest X-ray
..................................................................................................................................................................................................... Pathology The staff at The Sydney Private Hospital are anxious to provide the highest level of quality
cANcer ..................................................................................................................................................................................................... ECG care, compassion and individualised service.
Yes No Details .............................................................................................................................................................................................................
Date ............/............/................... Medical Officer's Signature: .........................................................................................
Please do not hesitate to discuss with our nurses any questions regarding your illness/
Site of cancer and type of cancer (if known) .............................................................................................................................................................................................
condition/treatment or hospital routine. Please let us know how we have done. We believe
gASTroINTeSTINAl ProBleMS: Dear Doctor, please fax this completed page immediately to hospital that you will be delighted with your stay with us. If not we welcome complaints so that we
Yes No Details ............................................................................................................................................................................................................. Main OT - 9716 3513 NSW Eye Centre - 9716 3537 can grow and continue to improve.
(Stomach ulcers, hiatus hernia, bowel disorders, Hepatitis B or C, etc) This consent is valid for the duration of your Surgical Admission. NoN PreScrIPTIoN MeDIcATIoNS PlEASE cOMPlEtE AND REtuRN FORM tO thE hOSPItAl AS SOON AS POSSIblE
High Blood Pressure? Yes No Sleep Apnoea? Yes No I ...................................................................................................................................................................................................................................... If you are taking any natural therapies, herbal medications or vitamins, please list them here
Have you had a fall in the last 3 months? Yes No Hepatitis or liver condition? Yes No of .................................................................................................................................................................................................................................... Name Strength Route Dose Frequency This hospital has a non-smoking policy, your co-operation would be appreciated.
Chest pain or "angina"? Yes No AIDS/HIV? Yes No request that the following operation / procedure ............................................................................................................................................................. We would like to avoid delay on your day of admission and to complete the necessary
Heart Attack? Yes No Kidney condition? Yes No ........................................................................................................................................................................................................................................ documentation and financial arrangements, we ask that you attend to the following.
Any other heart condition? Yes No Psychiatric Treatment? Yes No be performed *upon me/upon .........................................................................................................................................................................................
Complete the reverse side of this form and the Short History section.
Pace Maker - type? Yes No Depression/Anxiety? Yes No Following a discussion of *my/the patient's present condition, including the nature and likely results of the operation/procedure, I accept the professional
Lung problems needing hospital? Yes No Tuberculosis? Yes No opinion of Dr. ...................................................................................................................................... that this is the appropriate operation/procedure.
It is preferred that you fax or post this form to the hospital prior to admission.
Troublesome shortness of breath? Yes No Black-outs? Yes No Blood Transfusion/Products: Bring your health fund details on the day of admission to the hospital.
Blood transfusion? Yes No Blood clots or bleeding disorder? Yes No I understand why I may require a blood tranfusion / product and have discussed other relevant options with the doctor. I have been informed of the
risk and benefits, alternatives of a blood transfusion / product. I was given a Consumer Brochure. Bring your pension card or Health Care Card and Medicare Card.
Epilepsy? Yes No
Chronic bronchitis? Yes No c Yes I consent to a blood transfusion/product
Stroke? Yes No Current medications in original packaging, X-rays and CT scans.
Asthma? Yes No c No I do not consent to a blood transfusion/product
Do you smoke? Yes No If the account is subject to a Workers' Compensation or Third Party claim, please bring
Any other lung, chest or breathing problems? Yes No Although this operation/procedure is carried out with all due professional care and responsibility, I understand that in some circumstances the expected
Do you drink alcohol? Yes No result may not be achieved.
Diabetes? Yes No full details of the claim including a letter from your insurance company accepting liability

MR4a Implemented Nov 2000 Revised 07/13


MSO 73657 Implemented Nov 2000 Revised 07/13
Insulin dependent Table controlled Dementia? Yes No I also understand that complications may occur with any operation/procedure and I accept the possible risks associated with this operation/procedure.
for this admission.
The possible complications, risks and benefits have been explained to me by Dr. ............................................................................................................
Has your doctor ever prescribed for you Prednisone, cortisone or other steroids?....................................................................................Yes No
PRE-ADMISSION IS AN IMPORTANT STEP. It allows us to prepare for your stay and provide
Any condition that runs in the family e.g. thalassaema, muscular dystrophy? ..........................................................................................Yes No DAY SurgerY/eNDoScoPY PATIeNTS oNlY
I understand that if I am discharged on the same day as my anaesthetic/sedation and my surgery/procedure, I should not drive a motor vehicle or you with the very best of care. Please contact our Pre-Admission nursing staff at least 72
Do you have any other health conditions not above? e.g. hormone therapy, poor teeth, arthritis? ............................................................Yes No operate machinery or potentially dangerous appliances, drink alcoholic beverages or make critical decisions for 24 hours. hours prior to your admission on (02) 8775 1101.
Are you currently taking Aspirin, Dispirin, Warfarin, clopidogel, arthritis medication? .......................................................................Yes No I also understand that I must be accompanied home by a responsible adult. EYE SuRGERY PAtIENtS ONlY:
If Yes, have you ceased or will cease these medications? Yes No When? .. ................................................................................................ * Delete as required If you have red eyes, a cold sore (herpes simplex), a cold or flu like symptoms on the day prior to surgery please contact Our office staff will also be pleased to assist you with any questions about hospital
your doctor or the hospital.
Are you aware of any past history or present infections including VRE or Staph infections (MRSA)? .........................................................Yes No .............................................................................................................................................................................. ............................................................................................................................................................ procedure, costs or hospital insurance.
SIGNATURE OF PATIENT/GUARDIAN/RELATIVE/ATTORNEY *SIGNATURE OF WITNESS *Witness to signature only
Are you currently taking antibiotics? .......................................................................................................................................................Yes No
.............................................................................................................................................................................. ............................................................................................................................................................
Date ............/............/.................... Patient's Signature: ......................................................................................
Enquiries: (02) 9797 0555

AVI
Do you have any sores or wounds?.......................................................................................................................................................Yes No DATE FULL NAME OF WITNESS
MR 4b MR 4A MR 4A
MR 4c 6 7 8 1

TSPH MR4a 8pg Admission Form.indd 1-4 14/09/13 8:27 AM


UR No. .................................... visit ................................ Adm. Time
............................... Date of Adm. ........................
INDePeNDeNT PrIVATe HoSPITAlS oF AuSTrAlIA

If you have any further questions,


Treating Doctor ......................................................................................

PAtIENt INFORMAtION FORM


Date of Operation ............................................

coNSeNT For uSe oF INForMATIoN


AuStRAlIAN chARtER OF
please call the hospital on (02) 9797 0555 to be completed in full by patient and presented to the Admission Office one week prior to admission
FOR EMERgENCY ADMISSIONS, PATIENTS MAY gIvE THE INFORMATION OvER THE TELEPHONE. The Health Records Information Privacy Act 2002 No 71 and The National Privacy Principles prohibit the use of the personal information that Independent
Private Hospitals of Australia collects and holds about you for certain purposes in the event that you do not consent to the use of such information for
hEAlthcARE RIGhtS
Have you been a patient in this Hospital before Yes c No c oVerNIgHT AccoMMoDATIoN PreFerreD
We look forward to caring for you Year..............
Have you been admitted to hospital in the last 2 months?
(While no guarantee can be given, every effort will be made to
accommodate patients as requested)
those purposes.
The Australian Charter of Healthcare Rights describes the rights of patients and other people using the Australian

during your stay with us.


health system. These rights are essential to make sure that, wherever and whenever care is provided, it is of high
1 c No 2 c This Hospital 3 c Other Hospital Private Room Shared Ward Independent Private Hospitals of Australia would like you to indicate in this form whether or not you consent to the use of the personal information it quality and is safe.
PerSoNAl DeTAIlS PleASe PrINT HoSPITAl INSurANce holds about you for the purposes described below.
Name of Fund The Charter recognises that people receiving care and people providing care all have important parts to play in
Title: Mr., Mrs., Miss, Ms.
BUS ROUTE Surname
Table/Scale Membership No. You should note that in the event you do provide consent, the information would be used in an identified format. That is, your identity will be clear in any
achieving healthcare rights. The Charter allows patients, consumers, families, carers and services providing health

480,483 Given Names


Date joined this table
Is there an excess on your table?
Date Paid to
material generated for which you provide your consent.
care to share an understanding of the rights of people receiving health care. This helps everyone to work together
towards a safe and high quality health system. A genuine partnership between patients, consumers and providers
Previous Surname is important so that everyone achieves the best possible outcomes.
Contributors Name
Sex M F Date of Birth cAuSe oF INJurY (if applicable) You are under no obligation to provide consent to the use of your personal information for any of the purposes described below. In the event that you do
Guiding Principles
Nursing Home Hostel Date of Injury not consent, we will respect your wishes and will not use the information for that purpose in any identified format.
These three principles describe how
Address If injury, where did it occur: this Charter applies in the Australian
What can I expect from the Australian health system?
BUS ROUTE Postcode
0 Home 1 Residential Institution Please provide your consent to the use of your personal information for the purposes described below, by signing and dating the form. You may indicate health system.
406 2 School, Other Institution, Public Administrative Area 3 Sports & Athletics Area any specific area you DO NOT consent to by initialling the box. MY RIGhtS WhAt thIS MEANS

D)
Phone Private Business
LR 4 Street & Highway 5 Trade & Service Area
1 Everyone has the right to be able
O Mobile Access
PO
6 Industrial & Construction Site 7 Farm
Marital Status
to access health care and this right is I have a right to health care. I can access services to address my
ER
8 Other Specified Place 9 Unspecified Place essential for the Charter to be healthcare needs.
LI V Married Single Widowed Divorced Separated Defacto WorKer'S coMPeNSATIoN meaningful.
( Religion Liability must be accepted before admission
Initial To assist other medical practitioners or institutions who may treat me in the future but only to the extent
Safety
AY
necessary to treat the particular condition I have consulted the medical practitioner or institution about. This may
Date of Accident I have a right to receive safe I receive safe and high quality health
W Country of Birth include a requirement to forward relevant prior information for example anaesthesia records. 2 The Australian Government
E HIGH Aboriginality 1 Aborigine 2 Torres Strait Islander 3 Neither
Employer
commits to international agreements
and high quality care. services, provided with professional

HUM
Address To inform next of kin identified in my admission form of the outcome of treatment or to obtain consent to care, skill and competence.
Language spoken at home about human rights which recognise
Phone necessary treatment when I am not able to provide such consent. Respect
everyones right to have the highest
MAIN ENTRANCE Country of Perm. Residency Insurance Company possible standard of physical and I have a right to be shown The care provided shows respect to
at ROBERT STREET MeDIcAre No. Address To assist in the development of service delivery and planning in facilities owned and operated by mental health. respect, dignity and me and my culture, beliefs, values
Expiry Date Patients Line Number Phone Independent Private Hospitals of Australia. consideration. and personal characteristics.
Contact Name
PeNSIoN INForMATIoN
Claim No. (Compulsory to complete) For research and development projects undertaken by Independent Private Hospitals of Australia in its own right or in 3 Australia is a society made up of communication
Please fill out the following if you are a Pensioner or dependant conjunction with medical practitioners who work in the facility or drug companies. people with different cultures and I have a right to be informed I receive open, timely and appropriate
ROBERT STREET Pension No. Exp.
Your Solicitor
ways of life, and the Charter about services, treatment, communication about my health care
Address options and costs in a clear in a way I can understand.
H.C.C. No. Exp. To assist Independent Private Hospitals of Australia in providing practical training and education to medical, acknowledges and respects these
Phone and open way.
nursing and other allied health students. differences.
Veteran Affairs Card/Colour THIrD PArTY/TrANScoVer
NeXT oF KIN/coNTAcT 1 Date of Accident To assist Independent Private Hospitals of Australia in undertaking quality improvement activities. Participation
Name Claim No. I have a right to be included I may join in making decisions and
To enable Independent Private Hospitals of Australia to provide members of returned Service organisations and Ministers of in decisions and choices choices about my care and about
Address Insurance Company
religion with sufficient details to enable them to visit me whilst I am a patient in this facility. about my care. health service planning.
BUS ROUTE Postcode Address
To enable Independent Private Hospitals of Australia to provide access to my information to the Health Fund
413 CLISSOLD STREET Phone Private
Relationship
Business
Contact Name
Phone
of which I am a member if requested by the Health Fund to do so.
Privacy
I have a right to privacy and My personal privacy is maintained and
Your Solicitor confidentiality of my personal proper handling of my personal health
NeXT oF KIN/coNTAcT 2 To receive educational materials on the condition I was treated for at Independent Private Hospitals of Australia. information. and other information is assured.
Address
Name
PAYMeNT oF AccouNTS comment
Address The balance of account is payable at the time of admission and patients without
insurance are required to settle their account on admission.
Please initial in the box if you object to use of your personal information for the purposes described above. I have a right to comment on I can comment on or complain about
IMPORTANT ADMISSION INFORMATION Phone Private
Postcode
Business
INForMeD FINANcIAl coNSeNT I understand and agree to pay all hospital
accounts including any denial by - Health Insurance Funds, WorkCover, Transport I hereby consent to the use of my personal information for the purpose indicated above.
my care and to have my
concerns addressed.
my care and have my concerns dealt
with properly and promptly.
Accident Commision or any other relevant body. I understand that the hospital
Relationship
will not be liable for any valuables I bring to hospital. Signature If you do not understand or require a different language please make the
the Day Prior to Admission Referring Doctor Phone No. Signed
______________________________________________________________ Date ___________________
For further information please visit staff aware and they will assist you.
Address person responsible for account .............................................................. I have read and understand my rights
The afternoon prior to admission, phone reception on (02) 9797 0555 Print full name ___________________________________________________ www.safetyandquality.gov.au
Postcode *Write as above if same as Patient
between 1pm and 3pm to obtain your admission time
DAY PATIENT Yes No Surname* Irrespective of any request received, I direct you NoT to provide my personal information to (please specify name/details):
If Yes, Name of person collecting you on discharge Given Names* Patient Signature
.........................................................................................................................................................................................................................................
.............................................................................................................. Address*
Contact Telephone No. for above person ................................................ Postcode .........................................................................................................................................................................................................................................
2 3 MR 4A 4 MR 4b 5

TSPH MR4a 8pg Admission Form.indd 5-8 14/09/13 8:25 AM


UR No. .................................... visit ................................ Adm. Time
............................... Date of Adm. ........................
INDePeNDeNT PrIVATe HoSPITAlS oF AuSTrAlIA

If you have any further questions,


Treating Doctor ......................................................................................

PAtIENt INFORMAtION FORM


Date of Operation ............................................

coNSeNT For uSe oF INForMATIoN


AuStRAlIAN chARtER OF
please call the hospital on (02) 9797 0555 to be completed in full by patient and presented to the Admission Office one week prior to admission
FOR EMERgENCY ADMISSIONS, PATIENTS MAY gIvE THE INFORMATION OvER THE TELEPHONE. The Health Records Information Privacy Act 2002 No 71 and The National Privacy Principles prohibit the use of the personal information that Independent
Private Hospitals of Australia collects and holds about you for certain purposes in the event that you do not consent to the use of such information for
hEAlthcARE RIGhtS
Have you been a patient in this Hospital before Yes c No c oVerNIgHT AccoMMoDATIoN PreFerreD
We look forward to caring for you Year..............
Have you been admitted to hospital in the last 2 months?
(While no guarantee can be given, every effort will be made to
accommodate patients as requested)
those purposes.
The Australian Charter of Healthcare Rights describes the rights of patients and other people using the Australian

during your stay with us.


health system. These rights are essential to make sure that, wherever and whenever care is provided, it is of high
1 c No 2 c This Hospital 3 c Other Hospital Private Room Shared Ward Independent Private Hospitals of Australia would like you to indicate in this form whether or not you consent to the use of the personal information it quality and is safe.
PerSoNAl DeTAIlS PleASe PrINT HoSPITAl INSurANce holds about you for the purposes described below.
Name of Fund The Charter recognises that people receiving care and people providing care all have important parts to play in
Title: Mr., Mrs., Miss, Ms.
BUS ROUTE Surname
Table/Scale Membership No. You should note that in the event you do provide consent, the information would be used in an identified format. That is, your identity will be clear in any
achieving healthcare rights. The Charter allows patients, consumers, families, carers and services providing health

480,483 Given Names


Date joined this table
Is there an excess on your table?
Date Paid to
material generated for which you provide your consent.
care to share an understanding of the rights of people receiving health care. This helps everyone to work together
towards a safe and high quality health system. A genuine partnership between patients, consumers and providers
Previous Surname is important so that everyone achieves the best possible outcomes.
Contributors Name
Sex M F Date of Birth cAuSe oF INJurY (if applicable) You are under no obligation to provide consent to the use of your personal information for any of the purposes described below. In the event that you do
Guiding Principles
Nursing Home Hostel Date of Injury not consent, we will respect your wishes and will not use the information for that purpose in any identified format.
These three principles describe how
Address If injury, where did it occur: this Charter applies in the Australian
What can I expect from the Australian health system?
BUS ROUTE Postcode
0 Home 1 Residential Institution Please provide your consent to the use of your personal information for the purposes described below, by signing and dating the form. You may indicate health system.
406 2 School, Other Institution, Public Administrative Area 3 Sports & Athletics Area any specific area you DO NOT consent to by initialling the box. MY RIGhtS WhAt thIS MEANS

D)
Phone Private Business
LR 4 Street & Highway 5 Trade & Service Area
1 Everyone has the right to be able
O Mobile Access
PO
6 Industrial & Construction Site 7 Farm
Marital Status
to access health care and this right is I have a right to health care. I can access services to address my
ER
8 Other Specified Place 9 Unspecified Place essential for the Charter to be healthcare needs.
LI V Married Single Widowed Divorced Separated Defacto WorKer'S coMPeNSATIoN meaningful.
( Religion Liability must be accepted before admission
Initial To assist other medical practitioners or institutions who may treat me in the future but only to the extent
Safety
AY
necessary to treat the particular condition I have consulted the medical practitioner or institution about. This may
Date of Accident I have a right to receive safe I receive safe and high quality health
W Country of Birth include a requirement to forward relevant prior information for example anaesthesia records. 2 The Australian Government
E HIGH Aboriginality 1 Aborigine 2 Torres Strait Islander 3 Neither
Employer
commits to international agreements
and high quality care. services, provided with professional

HUM
Address To inform next of kin identified in my admission form of the outcome of treatment or to obtain consent to care, skill and competence.
Language spoken at home about human rights which recognise
Phone necessary treatment when I am not able to provide such consent. Respect
everyones right to have the highest
MAIN ENTRANCE Country of Perm. Residency Insurance Company possible standard of physical and I have a right to be shown The care provided shows respect to
at ROBERT STREET MeDIcAre No. Address To assist in the development of service delivery and planning in facilities owned and operated by mental health. respect, dignity and me and my culture, beliefs, values
Expiry Date Patients Line Number Phone Independent Private Hospitals of Australia. consideration. and personal characteristics.
Contact Name
PeNSIoN INForMATIoN
Claim No. (Compulsory to complete) For research and development projects undertaken by Independent Private Hospitals of Australia in its own right or in 3 Australia is a society made up of communication
Please fill out the following if you are a Pensioner or dependant conjunction with medical practitioners who work in the facility or drug companies. people with different cultures and I have a right to be informed I receive open, timely and appropriate
ROBERT STREET Pension No. Exp.
Your Solicitor
ways of life, and the Charter about services, treatment, communication about my health care
Address options and costs in a clear in a way I can understand.
H.C.C. No. Exp. To assist Independent Private Hospitals of Australia in providing practical training and education to medical, acknowledges and respects these
Phone and open way.
nursing and other allied health students. differences.
Veteran Affairs Card/Colour THIrD PArTY/TrANScoVer
NeXT oF KIN/coNTAcT 1 Date of Accident To assist Independent Private Hospitals of Australia in undertaking quality improvement activities. Participation
Name Claim No. I have a right to be included I may join in making decisions and
To enable Independent Private Hospitals of Australia to provide members of returned Service organisations and Ministers of in decisions and choices choices about my care and about
Address Insurance Company
religion with sufficient details to enable them to visit me whilst I am a patient in this facility. about my care. health service planning.
BUS ROUTE Postcode Address
To enable Independent Private Hospitals of Australia to provide access to my information to the Health Fund
413 CLISSOLD STREET Phone Private
Relationship
Business
Contact Name
Phone
of which I am a member if requested by the Health Fund to do so.
Privacy
I have a right to privacy and My personal privacy is maintained and
Your Solicitor confidentiality of my personal proper handling of my personal health
NeXT oF KIN/coNTAcT 2 To receive educational materials on the condition I was treated for at Independent Private Hospitals of Australia. information. and other information is assured.
Address
Name
PAYMeNT oF AccouNTS comment
Address The balance of account is payable at the time of admission and patients without
insurance are required to settle their account on admission.
Please initial in the box if you object to use of your personal information for the purposes described above. I have a right to comment on I can comment on or complain about
IMPORTANT ADMISSION INFORMATION Phone Private
Postcode
Business
INForMeD FINANcIAl coNSeNT I understand and agree to pay all hospital
accounts including any denial by - Health Insurance Funds, WorkCover, Transport I hereby consent to the use of my personal information for the purpose indicated above.
my care and to have my
concerns addressed.
my care and have my concerns dealt
with properly and promptly.
Accident Commision or any other relevant body. I understand that the hospital
Relationship
will not be liable for any valuables I bring to hospital. Signature If you do not understand or require a different language please make the
the Day Prior to Admission Referring Doctor Phone No. Signed
______________________________________________________________ Date ___________________
For further information please visit staff aware and they will assist you.
Address person responsible for account .............................................................. I have read and understand my rights
The afternoon prior to admission, phone reception on (02) 9797 0555 Print full name ___________________________________________________ www.safetyandquality.gov.au
Postcode *Write as above if same as Patient
between 1pm and 3pm to obtain your admission time
DAY PATIENT Yes No Surname* Irrespective of any request received, I direct you NoT to provide my personal information to (please specify name/details):
If Yes, Name of person collecting you on discharge Given Names* Patient Signature
.........................................................................................................................................................................................................................................
.............................................................................................................. Address*
Contact Telephone No. for above person ................................................ Postcode .........................................................................................................................................................................................................................................
2 3 MR 4A 4 MR 4b 5

TSPH MR4a 8pg Admission Form.indd 5-8 14/09/13 8:25 AM


UR No. .................................... visit ................................ Adm. Time
............................... Date of Adm. ........................
INDePeNDeNT PrIVATe HoSPITAlS oF AuSTrAlIA

If you have any further questions,


Treating Doctor ......................................................................................

PAtIENt INFORMAtION FORM


Date of Operation ............................................

coNSeNT For uSe oF INForMATIoN


AuStRAlIAN chARtER OF
please call the hospital on (02) 9797 0555 to be completed in full by patient and presented to the Admission Office one week prior to admission
FOR EMERgENCY ADMISSIONS, PATIENTS MAY gIvE THE INFORMATION OvER THE TELEPHONE. The Health Records Information Privacy Act 2002 No 71 and The National Privacy Principles prohibit the use of the personal information that Independent
Private Hospitals of Australia collects and holds about you for certain purposes in the event that you do not consent to the use of such information for
hEAlthcARE RIGhtS
Have you been a patient in this Hospital before Yes c No c oVerNIgHT AccoMMoDATIoN PreFerreD
We look forward to caring for you Year..............
Have you been admitted to hospital in the last 2 months?
(While no guarantee can be given, every effort will be made to
accommodate patients as requested)
those purposes.
The Australian Charter of Healthcare Rights describes the rights of patients and other people using the Australian

during your stay with us.


health system. These rights are essential to make sure that, wherever and whenever care is provided, it is of high
1 c No 2 c This Hospital 3 c Other Hospital Private Room Shared Ward Independent Private Hospitals of Australia would like you to indicate in this form whether or not you consent to the use of the personal information it quality and is safe.
PerSoNAl DeTAIlS PleASe PrINT HoSPITAl INSurANce holds about you for the purposes described below.
Name of Fund The Charter recognises that people receiving care and people providing care all have important parts to play in
Title: Mr., Mrs., Miss, Ms.
BUS ROUTE Surname
Table/Scale Membership No. You should note that in the event you do provide consent, the information would be used in an identified format. That is, your identity will be clear in any
achieving healthcare rights. The Charter allows patients, consumers, families, carers and services providing health

480,483 Given Names


Date joined this table
Is there an excess on your table?
Date Paid to
material generated for which you provide your consent.
care to share an understanding of the rights of people receiving health care. This helps everyone to work together
towards a safe and high quality health system. A genuine partnership between patients, consumers and providers
Previous Surname is important so that everyone achieves the best possible outcomes.
Contributors Name
Sex M F Date of Birth cAuSe oF INJurY (if applicable) You are under no obligation to provide consent to the use of your personal information for any of the purposes described below. In the event that you do
Guiding Principles
Nursing Home Hostel Date of Injury not consent, we will respect your wishes and will not use the information for that purpose in any identified format.
These three principles describe how
Address If injury, where did it occur: this Charter applies in the Australian
What can I expect from the Australian health system?
BUS ROUTE Postcode
0 Home 1 Residential Institution Please provide your consent to the use of your personal information for the purposes described below, by signing and dating the form. You may indicate health system.
406 2 School, Other Institution, Public Administrative Area 3 Sports & Athletics Area any specific area you DO NOT consent to by initialling the box. MY RIGhtS WhAt thIS MEANS

D)
Phone Private Business
LR 4 Street & Highway 5 Trade & Service Area
1 Everyone has the right to be able
O Mobile Access
PO
6 Industrial & Construction Site 7 Farm
Marital Status
to access health care and this right is I have a right to health care. I can access services to address my
ER
8 Other Specified Place 9 Unspecified Place essential for the Charter to be healthcare needs.
LI V Married Single Widowed Divorced Separated Defacto WorKer'S coMPeNSATIoN meaningful.
( Religion Liability must be accepted before admission
Initial To assist other medical practitioners or institutions who may treat me in the future but only to the extent
Safety
AY
necessary to treat the particular condition I have consulted the medical practitioner or institution about. This may
Date of Accident I have a right to receive safe I receive safe and high quality health
W Country of Birth include a requirement to forward relevant prior information for example anaesthesia records. 2 The Australian Government
E HIGH Aboriginality 1 Aborigine 2 Torres Strait Islander 3 Neither
Employer
commits to international agreements
and high quality care. services, provided with professional

HUM
Address To inform next of kin identified in my admission form of the outcome of treatment or to obtain consent to care, skill and competence.
Language spoken at home about human rights which recognise
Phone necessary treatment when I am not able to provide such consent. Respect
everyones right to have the highest
MAIN ENTRANCE Country of Perm. Residency Insurance Company possible standard of physical and I have a right to be shown The care provided shows respect to
at ROBERT STREET MeDIcAre No. Address To assist in the development of service delivery and planning in facilities owned and operated by mental health. respect, dignity and me and my culture, beliefs, values
Expiry Date Patients Line Number Phone Independent Private Hospitals of Australia. consideration. and personal characteristics.
Contact Name
PeNSIoN INForMATIoN
Claim No. (Compulsory to complete) For research and development projects undertaken by Independent Private Hospitals of Australia in its own right or in 3 Australia is a society made up of communication
Please fill out the following if you are a Pensioner or dependant conjunction with medical practitioners who work in the facility or drug companies. people with different cultures and I have a right to be informed I receive open, timely and appropriate
ROBERT STREET Pension No. Exp.
Your Solicitor
ways of life, and the Charter about services, treatment, communication about my health care
Address options and costs in a clear in a way I can understand.
H.C.C. No. Exp. To assist Independent Private Hospitals of Australia in providing practical training and education to medical, acknowledges and respects these
Phone and open way.
nursing and other allied health students. differences.
Veteran Affairs Card/Colour THIrD PArTY/TrANScoVer
NeXT oF KIN/coNTAcT 1 Date of Accident To assist Independent Private Hospitals of Australia in undertaking quality improvement activities. Participation
Name Claim No. I have a right to be included I may join in making decisions and
To enable Independent Private Hospitals of Australia to provide members of returned Service organisations and Ministers of in decisions and choices choices about my care and about
Address Insurance Company
religion with sufficient details to enable them to visit me whilst I am a patient in this facility. about my care. health service planning.
BUS ROUTE Postcode Address
To enable Independent Private Hospitals of Australia to provide access to my information to the Health Fund
413 CLISSOLD STREET Phone Private
Relationship
Business
Contact Name
Phone
of which I am a member if requested by the Health Fund to do so.
Privacy
I have a right to privacy and My personal privacy is maintained and
Your Solicitor confidentiality of my personal proper handling of my personal health
NeXT oF KIN/coNTAcT 2 To receive educational materials on the condition I was treated for at Independent Private Hospitals of Australia. information. and other information is assured.
Address
Name
PAYMeNT oF AccouNTS comment
Address The balance of account is payable at the time of admission and patients without
insurance are required to settle their account on admission.
Please initial in the box if you object to use of your personal information for the purposes described above. I have a right to comment on I can comment on or complain about
IMPORTANT ADMISSION INFORMATION Phone Private
Postcode
Business
INForMeD FINANcIAl coNSeNT I understand and agree to pay all hospital
accounts including any denial by - Health Insurance Funds, WorkCover, Transport I hereby consent to the use of my personal information for the purpose indicated above.
my care and to have my
concerns addressed.
my care and have my concerns dealt
with properly and promptly.
Accident Commision or any other relevant body. I understand that the hospital
Relationship
will not be liable for any valuables I bring to hospital. Signature If you do not understand or require a different language please make the
the Day Prior to Admission Referring Doctor Phone No. Signed
______________________________________________________________ Date ___________________
For further information please visit staff aware and they will assist you.
Address person responsible for account .............................................................. I have read and understand my rights
The afternoon prior to admission, phone reception on (02) 9797 0555 Print full name ___________________________________________________ www.safetyandquality.gov.au
Postcode *Write as above if same as Patient
between 1pm and 3pm to obtain your admission time
DAY PATIENT Yes No Surname* Irrespective of any request received, I direct you NoT to provide my personal information to (please specify name/details):
If Yes, Name of person collecting you on discharge Given Names* Patient Signature
.........................................................................................................................................................................................................................................
.............................................................................................................. Address*
Contact Telephone No. for above person ................................................ Postcode .........................................................................................................................................................................................................................................
2 3 MR 4A 4 MR 4b 5

TSPH MR4a 8pg Admission Form.indd 5-8 14/09/13 8:25 AM


UR No. .................................... visit ................................ Adm. Time
............................... Date of Adm. ........................
INDePeNDeNT PrIVATe HoSPITAlS oF AuSTrAlIA

If you have any further questions,


Treating Doctor ......................................................................................

PAtIENt INFORMAtION FORM


Date of Operation ............................................

coNSeNT For uSe oF INForMATIoN


AuStRAlIAN chARtER OF
please call the hospital on (02) 9797 0555 to be completed in full by patient and presented to the Admission Office one week prior to admission
FOR EMERgENCY ADMISSIONS, PATIENTS MAY gIvE THE INFORMATION OvER THE TELEPHONE. The Health Records Information Privacy Act 2002 No 71 and The National Privacy Principles prohibit the use of the personal information that Independent
Private Hospitals of Australia collects and holds about you for certain purposes in the event that you do not consent to the use of such information for
hEAlthcARE RIGhtS
Have you been a patient in this Hospital before Yes c No c oVerNIgHT AccoMMoDATIoN PreFerreD
We look forward to caring for you Year..............
Have you been admitted to hospital in the last 2 months?
(While no guarantee can be given, every effort will be made to
accommodate patients as requested)
those purposes.
The Australian Charter of Healthcare Rights describes the rights of patients and other people using the Australian

during your stay with us.


health system. These rights are essential to make sure that, wherever and whenever care is provided, it is of high
1 c No 2 c This Hospital 3 c Other Hospital Private Room Shared Ward Independent Private Hospitals of Australia would like you to indicate in this form whether or not you consent to the use of the personal information it quality and is safe.
PerSoNAl DeTAIlS PleASe PrINT HoSPITAl INSurANce holds about you for the purposes described below.
Name of Fund The Charter recognises that people receiving care and people providing care all have important parts to play in
Title: Mr., Mrs., Miss, Ms.
BUS ROUTE Surname
Table/Scale Membership No. You should note that in the event you do provide consent, the information would be used in an identified format. That is, your identity will be clear in any
achieving healthcare rights. The Charter allows patients, consumers, families, carers and services providing health

480,483 Given Names


Date joined this table
Is there an excess on your table?
Date Paid to
material generated for which you provide your consent.
care to share an understanding of the rights of people receiving health care. This helps everyone to work together
towards a safe and high quality health system. A genuine partnership between patients, consumers and providers
Previous Surname is important so that everyone achieves the best possible outcomes.
Contributors Name
Sex M F Date of Birth cAuSe oF INJurY (if applicable) You are under no obligation to provide consent to the use of your personal information for any of the purposes described below. In the event that you do
Guiding Principles
Nursing Home Hostel Date of Injury not consent, we will respect your wishes and will not use the information for that purpose in any identified format.
These three principles describe how
Address If injury, where did it occur: this Charter applies in the Australian
What can I expect from the Australian health system?
BUS ROUTE Postcode
0 Home 1 Residential Institution Please provide your consent to the use of your personal information for the purposes described below, by signing and dating the form. You may indicate health system.
406 2 School, Other Institution, Public Administrative Area 3 Sports & Athletics Area any specific area you DO NOT consent to by initialling the box. MY RIGhtS WhAt thIS MEANS

D)
Phone Private Business
LR 4 Street & Highway 5 Trade & Service Area
1 Everyone has the right to be able
O Mobile Access
PO
6 Industrial & Construction Site 7 Farm
Marital Status
to access health care and this right is I have a right to health care. I can access services to address my
ER
8 Other Specified Place 9 Unspecified Place essential for the Charter to be healthcare needs.
LI V Married Single Widowed Divorced Separated Defacto WorKer'S coMPeNSATIoN meaningful.
( Religion Liability must be accepted before admission
Initial To assist other medical practitioners or institutions who may treat me in the future but only to the extent
Safety
AY
necessary to treat the particular condition I have consulted the medical practitioner or institution about. This may
Date of Accident I have a right to receive safe I receive safe and high quality health
W Country of Birth include a requirement to forward relevant prior information for example anaesthesia records. 2 The Australian Government
E HIGH Aboriginality 1 Aborigine 2 Torres Strait Islander 3 Neither
Employer
commits to international agreements
and high quality care. services, provided with professional

HUM
Address To inform next of kin identified in my admission form of the outcome of treatment or to obtain consent to care, skill and competence.
Language spoken at home about human rights which recognise
Phone necessary treatment when I am not able to provide such consent. Respect
everyones right to have the highest
MAIN ENTRANCE Country of Perm. Residency Insurance Company possible standard of physical and I have a right to be shown The care provided shows respect to
at ROBERT STREET MeDIcAre No. Address To assist in the development of service delivery and planning in facilities owned and operated by mental health. respect, dignity and me and my culture, beliefs, values
Expiry Date Patients Line Number Phone Independent Private Hospitals of Australia. consideration. and personal characteristics.
Contact Name
PeNSIoN INForMATIoN
Claim No. (Compulsory to complete) For research and development projects undertaken by Independent Private Hospitals of Australia in its own right or in 3 Australia is a society made up of communication
Please fill out the following if you are a Pensioner or dependant conjunction with medical practitioners who work in the facility or drug companies. people with different cultures and I have a right to be informed I receive open, timely and appropriate
ROBERT STREET Pension No. Exp.
Your Solicitor
ways of life, and the Charter about services, treatment, communication about my health care
Address options and costs in a clear in a way I can understand.
H.C.C. No. Exp. To assist Independent Private Hospitals of Australia in providing practical training and education to medical, acknowledges and respects these
Phone and open way.
nursing and other allied health students. differences.
Veteran Affairs Card/Colour THIrD PArTY/TrANScoVer
NeXT oF KIN/coNTAcT 1 Date of Accident To assist Independent Private Hospitals of Australia in undertaking quality improvement activities. Participation
Name Claim No. I have a right to be included I may join in making decisions and
To enable Independent Private Hospitals of Australia to provide members of returned Service organisations and Ministers of in decisions and choices choices about my care and about
Address Insurance Company
religion with sufficient details to enable them to visit me whilst I am a patient in this facility. about my care. health service planning.
BUS ROUTE Postcode Address
To enable Independent Private Hospitals of Australia to provide access to my information to the Health Fund
413 CLISSOLD STREET Phone Private
Relationship
Business
Contact Name
Phone
of which I am a member if requested by the Health Fund to do so.
Privacy
I have a right to privacy and My personal privacy is maintained and
Your Solicitor confidentiality of my personal proper handling of my personal health
NeXT oF KIN/coNTAcT 2 To receive educational materials on the condition I was treated for at Independent Private Hospitals of Australia. information. and other information is assured.
Address
Name
PAYMeNT oF AccouNTS comment
Address The balance of account is payable at the time of admission and patients without
insurance are required to settle their account on admission.
Please initial in the box if you object to use of your personal information for the purposes described above. I have a right to comment on I can comment on or complain about
IMPORTANT ADMISSION INFORMATION Phone Private
Postcode
Business
INForMeD FINANcIAl coNSeNT I understand and agree to pay all hospital
accounts including any denial by - Health Insurance Funds, WorkCover, Transport I hereby consent to the use of my personal information for the purpose indicated above.
my care and to have my
concerns addressed.
my care and have my concerns dealt
with properly and promptly.
Accident Commision or any other relevant body. I understand that the hospital
Relationship
will not be liable for any valuables I bring to hospital. Signature If you do not understand or require a different language please make the
the Day Prior to Admission Referring Doctor Phone No. Signed
______________________________________________________________ Date ___________________
For further information please visit staff aware and they will assist you.
Address person responsible for account .............................................................. I have read and understand my rights
The afternoon prior to admission, phone reception on (02) 9797 0555 Print full name ___________________________________________________ www.safetyandquality.gov.au
Postcode *Write as above if same as Patient
between 1pm and 3pm to obtain your admission time
DAY PATIENT Yes No Surname* Irrespective of any request received, I direct you NoT to provide my personal information to (please specify name/details):
If Yes, Name of person collecting you on discharge Given Names* Patient Signature
.........................................................................................................................................................................................................................................
.............................................................................................................. Address*
Contact Telephone No. for above person ................................................ Postcode .........................................................................................................................................................................................................................................
2 3 MR 4A 4 MR 4b 5

TSPH MR4a 8pg Admission Form.indd 5-8 14/09/13 8:25 AM


Patient Health Questionnaire - Please Tick Request for Surgical Operation, Procedure and / or Medical Treatment lIST Your curreNT MeDIcATIoNS
Do you have an advance care directive and/or treatment-limiting orders?............................................................................................... Yes No Include all tablets, capsules, puffers, patches, insulin, eye drops.
If Yes, please bring with you and advise nursing staff. ADMITTING DOCTOR SURNAME CHRISTIAN NAMES
Consult your GP or surgeon if you are unsure of any details. 63 Victoria Street,
Bring all your current medications to hospital in their original package. Ashfield NSW 2131
ANAeSTHeTIc HISTorY ADDRESS
PATIENT HISTORY/Summary of Physical Exam
Telephone (02) 9797 0555
Have you or any family member had a problem with an anaesthetic previously? .......................................................................................................... Yes No Medication Strength Route Dose Frequency
1. Healthy Patient POSTCODE ABN 97 094 662 914 ACN 094 662 914 Facsimile (02) 9798 7555
Have you or a member of your family had special problems with anaesthetics? ............................................................................................................ Yes No 2. Mild Systematic Disease no functional limitations PHONE D.O.B SEX
If Yes, please comment ............................................................................................................................................................................................................................ 3. Severe Disease with definite functional limitations MALE FEMALE
4. Severe Disease that is a constant threat to life DATE OF ADMISSION OPERATION DATE ESTIMATED STAY

AllergIeS Other comments: ............/.........../............. ............/.........../............. A Total Quality Management Facility


Do you have any allergies or sensitivities?.......Yes No Known Latex Allergy?.......Yes No LA GA Neurolept
Relevant HEALTH FUND MEMBERSHIP NUMBER
Do you have any food allergies?.......Yes No Special diet requirements....................................................................................................................................... Infections MRSA VRE Hep B or C HIV
If Yes, please provide details, including allergies to any medications, tapes, lotions, foods etc. .................................................................................................................
Known Allergies: ........................................................................................................................................................................................................
PRE-ADMISSION FORMS
.................................................................................................................................................................................................................................................................

Welcome!
Provisional Diagnosis: ................................................................................................................................................................................................
Other Conditions Present/History of Complications / Aspirin Non-Steroidal Antiflammatory
crueTZFelDT JAKoB DISeASe (cJD): (All patients must complete these questions)
.................................................................................................................................................................................................................................
Did you have a dura mater graft between 1972 and 1989? ........................................................................................................................................... Yes No
Proposed Operation/Treatment:.................................................................................................................................................................................
Do you have a history of 2 or more relatives with CJD or other unspecified progressive neurological disorder? ............................................................. Yes No The management and nurses of The Sydney Private Hospital will strive to make your stay
.................................................................................................................................................................................................................................
Did you receive human pituitary hormones (growth hormones, gonadotophins) prior to 1985? ...................................................................................... Yes No with us as comfortable and pleasant as possible.
.............................................................................................................................................................. Item No. (if known) ..................................
Have you suffered from a recent, progressive dementia the cause of which has not been identified? ............................................................................ Yes No
Prostheses Required: Yes No Prostheses Informed Financial Consent given: Yes No We work as a team and your care, welfare and comfort are our main concern.
Have you been involved in a look-back for CJD or received an In Medical Confidence letter notifying you of a potential exposure to CJD? .............. Yes No
Specific Pre-Operative Instructions (incl Instrumentation) : ........................................................................................................... Chest X-ray
..................................................................................................................................................................................................... Pathology The staff at The Sydney Private Hospital are anxious to provide the highest level of quality
cANcer ..................................................................................................................................................................................................... ECG care, compassion and individualised service.
Yes No Details .............................................................................................................................................................................................................
Date ............/............/................... Medical Officer's Signature: .........................................................................................
Please do not hesitate to discuss with our nurses any questions regarding your illness/
Site of cancer and type of cancer (if known) .............................................................................................................................................................................................
condition/treatment or hospital routine. Please let us know how we have done. We believe
gASTroINTeSTINAl ProBleMS: Dear Doctor, please fax this completed page immediately to hospital that you will be delighted with your stay with us. If not we welcome complaints so that we
Yes No Details ............................................................................................................................................................................................................. Main OT - 9716 3513 NSW Eye Centre - 9716 3537 can grow and continue to improve.
(Stomach ulcers, hiatus hernia, bowel disorders, Hepatitis B or C, etc) This consent is valid for the duration of your Surgical Admission. NoN PreScrIPTIoN MeDIcATIoNS PlEASE cOMPlEtE AND REtuRN FORM tO thE hOSPItAl AS SOON AS POSSIblE
High Blood Pressure? Yes No Sleep Apnoea? Yes No I ...................................................................................................................................................................................................................................... If you are taking any natural therapies, herbal medications or vitamins, please list them here
Have you had a fall in the last 3 months? Yes No Hepatitis or liver condition? Yes No of .................................................................................................................................................................................................................................... Name Strength Route Dose Frequency This hospital has a non-smoking policy, your co-operation would be appreciated.
Chest pain or "angina"? Yes No AIDS/HIV? Yes No request that the following operation / procedure ............................................................................................................................................................. We would like to avoid delay on your day of admission and to complete the necessary
Heart Attack? Yes No Kidney condition? Yes No ........................................................................................................................................................................................................................................ documentation and financial arrangements, we ask that you attend to the following.
Any other heart condition? Yes No Psychiatric Treatment? Yes No be performed *upon me/upon .........................................................................................................................................................................................
Complete the reverse side of this form and the Short History section.
Pace Maker - type? Yes No Depression/Anxiety? Yes No Following a discussion of *my/the patient's present condition, including the nature and likely results of the operation/procedure, I accept the professional
Lung problems needing hospital? Yes No Tuberculosis? Yes No opinion of Dr. ...................................................................................................................................... that this is the appropriate operation/procedure.
It is preferred that you fax or post this form to the hospital prior to admission.
Troublesome shortness of breath? Yes No Black-outs? Yes No Blood Transfusion/Products: Bring your health fund details on the day of admission to the hospital.
Blood transfusion? Yes No Blood clots or bleeding disorder? Yes No I understand why I may require a blood tranfusion / product and have discussed other relevant options with the doctor. I have been informed of the
risk and benefits, alternatives of a blood transfusion / product. I was given a Consumer Brochure. Bring your pension card or Health Care Card and Medicare Card.
Epilepsy? Yes No
Chronic bronchitis? Yes No c Yes I consent to a blood transfusion/product
Stroke? Yes No Current medications in original packaging, X-rays and CT scans.
Asthma? Yes No c No I do not consent to a blood transfusion/product
Do you smoke? Yes No If the account is subject to a Workers' Compensation or Third Party claim, please bring
Any other lung, chest or breathing problems? Yes No Although this operation/procedure is carried out with all due professional care and responsibility, I understand that in some circumstances the expected
Do you drink alcohol? Yes No result may not be achieved.
Diabetes? Yes No full details of the claim including a letter from your insurance company accepting liability

MR4a Implemented Nov 2000 Revised 07/13


MSO 73657 Implemented Nov 2000 Revised 07/13
Insulin dependent Table controlled Dementia? Yes No I also understand that complications may occur with any operation/procedure and I accept the possible risks associated with this operation/procedure.
for this admission.
The possible complications, risks and benefits have been explained to me by Dr. ............................................................................................................
Has your doctor ever prescribed for you Prednisone, cortisone or other steroids?....................................................................................Yes No
PRE-ADMISSION IS AN IMPORTANT STEP. It allows us to prepare for your stay and provide
Any condition that runs in the family e.g. thalassaema, muscular dystrophy? ..........................................................................................Yes No DAY SurgerY/eNDoScoPY PATIeNTS oNlY
I understand that if I am discharged on the same day as my anaesthetic/sedation and my surgery/procedure, I should not drive a motor vehicle or you with the very best of care. Please contact our Pre-Admission nursing staff at least 72
Do you have any other health conditions not above? e.g. hormone therapy, poor teeth, arthritis? ............................................................Yes No operate machinery or potentially dangerous appliances, drink alcoholic beverages or make critical decisions for 24 hours. hours prior to your admission on (02) 8775 1101.
Are you currently taking Aspirin, Dispirin, Warfarin, clopidogel, arthritis medication? .......................................................................Yes No I also understand that I must be accompanied home by a responsible adult. EYE SuRGERY PAtIENtS ONlY:
If Yes, have you ceased or will cease these medications? Yes No When? .. ................................................................................................ * Delete as required If you have red eyes, a cold sore (herpes simplex), a cold or flu like symptoms on the day prior to surgery please contact Our office staff will also be pleased to assist you with any questions about hospital
your doctor or the hospital.
Are you aware of any past history or present infections including VRE or Staph infections (MRSA)? .........................................................Yes No .............................................................................................................................................................................. ............................................................................................................................................................ procedure, costs or hospital insurance.
SIGNATURE OF PATIENT/GUARDIAN/RELATIVE/ATTORNEY *SIGNATURE OF WITNESS *Witness to signature only
Are you currently taking antibiotics? .......................................................................................................................................................Yes No
.............................................................................................................................................................................. ............................................................................................................................................................
Date ............/............/.................... Patient's Signature: ......................................................................................
Enquiries: (02) 9797 0555

AVI
Do you have any sores or wounds?.......................................................................................................................................................Yes No DATE FULL NAME OF WITNESS
MR 4b MR 4A MR 4A
MR 4c 6 7 8 1

TSPH MR4a 8pg Admission Form.indd 1-4 14/09/13 8:27 AM


Patient Health Questionnaire - Please Tick Request for Surgical Operation, Procedure and / or Medical Treatment lIST Your curreNT MeDIcATIoNS
Do you have an advance care directive and/or treatment-limiting orders?............................................................................................... Yes No Include all tablets, capsules, puffers, patches, insulin, eye drops.
If Yes, please bring with you and advise nursing staff. ADMITTING DOCTOR SURNAME CHRISTIAN NAMES
Consult your GP or surgeon if you are unsure of any details. 63 Victoria Street,
Bring all your current medications to hospital in their original package. Ashfield NSW 2131
ANAeSTHeTIc HISTorY ADDRESS
PATIENT HISTORY/Summary of Physical Exam
Telephone (02) 9797 0555
Have you or any family member had a problem with an anaesthetic previously? .......................................................................................................... Yes No Medication Strength Route Dose Frequency
1. Healthy Patient POSTCODE ABN 97 094 662 914 ACN 094 662 914 Facsimile (02) 9798 7555
Have you or a member of your family had special problems with anaesthetics? ............................................................................................................ Yes No 2. Mild Systematic Disease no functional limitations PHONE D.O.B SEX
If Yes, please comment ............................................................................................................................................................................................................................ 3. Severe Disease with definite functional limitations MALE FEMALE
4. Severe Disease that is a constant threat to life DATE OF ADMISSION OPERATION DATE ESTIMATED STAY

AllergIeS Other comments: ............/.........../............. ............/.........../............. A Total Quality Management Facility


Do you have any allergies or sensitivities?.......Yes No Known Latex Allergy?.......Yes No LA GA Neurolept
Relevant HEALTH FUND MEMBERSHIP NUMBER
Do you have any food allergies?.......Yes No Special diet requirements....................................................................................................................................... Infections MRSA VRE Hep B or C HIV
If Yes, please provide details, including allergies to any medications, tapes, lotions, foods etc. .................................................................................................................
Known Allergies: ........................................................................................................................................................................................................
PRE-ADMISSION FORMS
.................................................................................................................................................................................................................................................................

Welcome!
Provisional Diagnosis: ................................................................................................................................................................................................
Other Conditions Present/History of Complications / Aspirin Non-Steroidal Antiflammatory
crueTZFelDT JAKoB DISeASe (cJD): (All patients must complete these questions)
.................................................................................................................................................................................................................................
Did you have a dura mater graft between 1972 and 1989? ........................................................................................................................................... Yes No
Proposed Operation/Treatment:.................................................................................................................................................................................
Do you have a history of 2 or more relatives with CJD or other unspecified progressive neurological disorder? ............................................................. Yes No The management and nurses of The Sydney Private Hospital will strive to make your stay
.................................................................................................................................................................................................................................
Did you receive human pituitary hormones (growth hormones, gonadotophins) prior to 1985? ...................................................................................... Yes No with us as comfortable and pleasant as possible.
.............................................................................................................................................................. Item No. (if known) ..................................
Have you suffered from a recent, progressive dementia the cause of which has not been identified? ............................................................................ Yes No
Prostheses Required: Yes No Prostheses Informed Financial Consent given: Yes No We work as a team and your care, welfare and comfort are our main concern.
Have you been involved in a look-back for CJD or received an In Medical Confidence letter notifying you of a potential exposure to CJD? .............. Yes No
Specific Pre-Operative Instructions (incl Instrumentation) : ........................................................................................................... Chest X-ray
..................................................................................................................................................................................................... Pathology The staff at The Sydney Private Hospital are anxious to provide the highest level of quality
cANcer ..................................................................................................................................................................................................... ECG care, compassion and individualised service.
Yes No Details .............................................................................................................................................................................................................
Date ............/............/................... Medical Officer's Signature: .........................................................................................
Please do not hesitate to discuss with our nurses any questions regarding your illness/
Site of cancer and type of cancer (if known) .............................................................................................................................................................................................
condition/treatment or hospital routine. Please let us know how we have done. We believe
gASTroINTeSTINAl ProBleMS: Dear Doctor, please fax this completed page immediately to hospital that you will be delighted with your stay with us. If not we welcome complaints so that we
Yes No Details ............................................................................................................................................................................................................. Main OT - 9716 3513 NSW Eye Centre - 9716 3537 can grow and continue to improve.
(Stomach ulcers, hiatus hernia, bowel disorders, Hepatitis B or C, etc) This consent is valid for the duration of your Surgical Admission. NoN PreScrIPTIoN MeDIcATIoNS PlEASE cOMPlEtE AND REtuRN FORM tO thE hOSPItAl AS SOON AS POSSIblE
High Blood Pressure? Yes No Sleep Apnoea? Yes No I ...................................................................................................................................................................................................................................... If you are taking any natural therapies, herbal medications or vitamins, please list them here
Have you had a fall in the last 3 months? Yes No Hepatitis or liver condition? Yes No of .................................................................................................................................................................................................................................... Name Strength Route Dose Frequency This hospital has a non-smoking policy, your co-operation would be appreciated.
Chest pain or "angina"? Yes No AIDS/HIV? Yes No request that the following operation / procedure ............................................................................................................................................................. We would like to avoid delay on your day of admission and to complete the necessary
Heart Attack? Yes No Kidney condition? Yes No ........................................................................................................................................................................................................................................ documentation and financial arrangements, we ask that you attend to the following.
Any other heart condition? Yes No Psychiatric Treatment? Yes No be performed *upon me/upon .........................................................................................................................................................................................
Complete the reverse side of this form and the Short History section.
Pace Maker - type? Yes No Depression/Anxiety? Yes No Following a discussion of *my/the patient's present condition, including the nature and likely results of the operation/procedure, I accept the professional
Lung problems needing hospital? Yes No Tuberculosis? Yes No opinion of Dr. ...................................................................................................................................... that this is the appropriate operation/procedure.
It is preferred that you fax or post this form to the hospital prior to admission.
Troublesome shortness of breath? Yes No Black-outs? Yes No Blood Transfusion/Products: Bring your health fund details on the day of admission to the hospital.
Blood transfusion? Yes No Blood clots or bleeding disorder? Yes No I understand why I may require a blood tranfusion / product and have discussed other relevant options with the doctor. I have been informed of the
risk and benefits, alternatives of a blood transfusion / product. I was given a Consumer Brochure. Bring your pension card or Health Care Card and Medicare Card.
Epilepsy? Yes No
Chronic bronchitis? Yes No c Yes I consent to a blood transfusion/product
Stroke? Yes No Current medications in original packaging, X-rays and CT scans.
Asthma? Yes No c No I do not consent to a blood transfusion/product
Do you smoke? Yes No If the account is subject to a Workers' Compensation or Third Party claim, please bring
Any other lung, chest or breathing problems? Yes No Although this operation/procedure is carried out with all due professional care and responsibility, I understand that in some circumstances the expected
Do you drink alcohol? Yes No result may not be achieved.
Diabetes? Yes No full details of the claim including a letter from your insurance company accepting liability

MR4a Implemented Nov 2000 Revised 07/13


MSO 73657 Implemented Nov 2000 Revised 07/13
Insulin dependent Table controlled Dementia? Yes No I also understand that complications may occur with any operation/procedure and I accept the possible risks associated with this operation/procedure.
for this admission.
The possible complications, risks and benefits have been explained to me by Dr. ............................................................................................................
Has your doctor ever prescribed for you Prednisone, cortisone or other steroids?....................................................................................Yes No
PRE-ADMISSION IS AN IMPORTANT STEP. It allows us to prepare for your stay and provide
Any condition that runs in the family e.g. thalassaema, muscular dystrophy? ..........................................................................................Yes No DAY SurgerY/eNDoScoPY PATIeNTS oNlY
I understand that if I am discharged on the same day as my anaesthetic/sedation and my surgery/procedure, I should not drive a motor vehicle or you with the very best of care. Please contact our Pre-Admission nursing staff at least 72
Do you have any other health conditions not above? e.g. hormone therapy, poor teeth, arthritis? ............................................................Yes No operate machinery or potentially dangerous appliances, drink alcoholic beverages or make critical decisions for 24 hours. hours prior to your admission on (02) 8775 1101.
Are you currently taking Aspirin, Dispirin, Warfarin, clopidogel, arthritis medication? .......................................................................Yes No I also understand that I must be accompanied home by a responsible adult. EYE SuRGERY PAtIENtS ONlY:
If Yes, have you ceased or will cease these medications? Yes No When? .. ................................................................................................ * Delete as required If you have red eyes, a cold sore (herpes simplex), a cold or flu like symptoms on the day prior to surgery please contact Our office staff will also be pleased to assist you with any questions about hospital
your doctor or the hospital.
Are you aware of any past history or present infections including VRE or Staph infections (MRSA)? .........................................................Yes No .............................................................................................................................................................................. ............................................................................................................................................................ procedure, costs or hospital insurance.
SIGNATURE OF PATIENT/GUARDIAN/RELATIVE/ATTORNEY *SIGNATURE OF WITNESS *Witness to signature only
Are you currently taking antibiotics? .......................................................................................................................................................Yes No
.............................................................................................................................................................................. ............................................................................................................................................................
Date ............/............/.................... Patient's Signature: ......................................................................................
Enquiries: (02) 9797 0555

AVI
Do you have any sores or wounds?.......................................................................................................................................................Yes No DATE FULL NAME OF WITNESS
MR 4b MR 4A MR 4A
MR 4c 6 7 8 1

TSPH MR4a 8pg Admission Form.indd 1-4 14/09/13 8:27 AM


Patient Health Questionnaire - Please Tick Request for Surgical Operation, Procedure and / or Medical Treatment lIST Your curreNT MeDIcATIoNS
Do you have an advance care directive and/or treatment-limiting orders?............................................................................................... Yes No Include all tablets, capsules, puffers, patches, insulin, eye drops.
If Yes, please bring with you and advise nursing staff. ADMITTING DOCTOR SURNAME CHRISTIAN NAMES
Consult your GP or surgeon if you are unsure of any details. 63 Victoria Street,
Bring all your current medications to hospital in their original package. Ashfield NSW 2131
ANAeSTHeTIc HISTorY ADDRESS
PATIENT HISTORY/Summary of Physical Exam
Telephone (02) 9797 0555
Have you or any family member had a problem with an anaesthetic previously? .......................................................................................................... Yes No Medication Strength Route Dose Frequency
1. Healthy Patient POSTCODE ABN 97 094 662 914 ACN 094 662 914 Facsimile (02) 9798 7555
Have you or a member of your family had special problems with anaesthetics? ............................................................................................................ Yes No 2. Mild Systematic Disease no functional limitations PHONE D.O.B SEX
If Yes, please comment ............................................................................................................................................................................................................................ 3. Severe Disease with definite functional limitations MALE FEMALE
4. Severe Disease that is a constant threat to life DATE OF ADMISSION OPERATION DATE ESTIMATED STAY

AllergIeS Other comments: ............/.........../............. ............/.........../............. A Total Quality Management Facility


Do you have any allergies or sensitivities?.......Yes No Known Latex Allergy?.......Yes No LA GA Neurolept
Relevant HEALTH FUND MEMBERSHIP NUMBER
Do you have any food allergies?.......Yes No Special diet requirements....................................................................................................................................... Infections MRSA VRE Hep B or C HIV
If Yes, please provide details, including allergies to any medications, tapes, lotions, foods etc. .................................................................................................................
Known Allergies: ........................................................................................................................................................................................................
PRE-ADMISSION FORMS
.................................................................................................................................................................................................................................................................

Welcome!
Provisional Diagnosis: ................................................................................................................................................................................................
Other Conditions Present/History of Complications / Aspirin Non-Steroidal Antiflammatory
crueTZFelDT JAKoB DISeASe (cJD): (All patients must complete these questions)
.................................................................................................................................................................................................................................
Did you have a dura mater graft between 1972 and 1989? ........................................................................................................................................... Yes No
Proposed Operation/Treatment:.................................................................................................................................................................................
Do you have a history of 2 or more relatives with CJD or other unspecified progressive neurological disorder? ............................................................. Yes No The management and nurses of The Sydney Private Hospital will strive to make your stay
.................................................................................................................................................................................................................................
Did you receive human pituitary hormones (growth hormones, gonadotophins) prior to 1985? ...................................................................................... Yes No with us as comfortable and pleasant as possible.
.............................................................................................................................................................. Item No. (if known) ..................................
Have you suffered from a recent, progressive dementia the cause of which has not been identified? ............................................................................ Yes No
Prostheses Required: Yes No Prostheses Informed Financial Consent given: Yes No We work as a team and your care, welfare and comfort are our main concern.
Have you been involved in a look-back for CJD or received an In Medical Confidence letter notifying you of a potential exposure to CJD? .............. Yes No
Specific Pre-Operative Instructions (incl Instrumentation) : ........................................................................................................... Chest X-ray
..................................................................................................................................................................................................... Pathology The staff at The Sydney Private Hospital are anxious to provide the highest level of quality
cANcer ..................................................................................................................................................................................................... ECG care, compassion and individualised service.
Yes No Details .............................................................................................................................................................................................................
Date ............/............/................... Medical Officer's Signature: .........................................................................................
Please do not hesitate to discuss with our nurses any questions regarding your illness/
Site of cancer and type of cancer (if known) .............................................................................................................................................................................................
condition/treatment or hospital routine. Please let us know how we have done. We believe
gASTroINTeSTINAl ProBleMS: Dear Doctor, please fax this completed page immediately to hospital that you will be delighted with your stay with us. If not we welcome complaints so that we
Yes No Details ............................................................................................................................................................................................................. Main OT - 9716 3513 NSW Eye Centre - 9716 3537 can grow and continue to improve.
(Stomach ulcers, hiatus hernia, bowel disorders, Hepatitis B or C, etc) This consent is valid for the duration of your Surgical Admission. NoN PreScrIPTIoN MeDIcATIoNS PlEASE cOMPlEtE AND REtuRN FORM tO thE hOSPItAl AS SOON AS POSSIblE
High Blood Pressure? Yes No Sleep Apnoea? Yes No I ...................................................................................................................................................................................................................................... If you are taking any natural therapies, herbal medications or vitamins, please list them here
Have you had a fall in the last 3 months? Yes No Hepatitis or liver condition? Yes No of .................................................................................................................................................................................................................................... Name Strength Route Dose Frequency This hospital has a non-smoking policy, your co-operation would be appreciated.
Chest pain or "angina"? Yes No AIDS/HIV? Yes No request that the following operation / procedure ............................................................................................................................................................. We would like to avoid delay on your day of admission and to complete the necessary
Heart Attack? Yes No Kidney condition? Yes No ........................................................................................................................................................................................................................................ documentation and financial arrangements, we ask that you attend to the following.
Any other heart condition? Yes No Psychiatric Treatment? Yes No be performed *upon me/upon .........................................................................................................................................................................................
Complete the reverse side of this form and the Short History section.
Pace Maker - type? Yes No Depression/Anxiety? Yes No Following a discussion of *my/the patient's present condition, including the nature and likely results of the operation/procedure, I accept the professional
Lung problems needing hospital? Yes No Tuberculosis? Yes No opinion of Dr. ...................................................................................................................................... that this is the appropriate operation/procedure.
It is preferred that you fax or post this form to the hospital prior to admission.
Troublesome shortness of breath? Yes No Black-outs? Yes No Blood Transfusion/Products: Bring your health fund details on the day of admission to the hospital.
Blood transfusion? Yes No Blood clots or bleeding disorder? Yes No I understand why I may require a blood tranfusion / product and have discussed other relevant options with the doctor. I have been informed of the
risk and benefits, alternatives of a blood transfusion / product. I was given a Consumer Brochure. Bring your pension card or Health Care Card and Medicare Card.
Epilepsy? Yes No
Chronic bronchitis? Yes No c Yes I consent to a blood transfusion/product
Stroke? Yes No Current medications in original packaging, X-rays and CT scans.
Asthma? Yes No c No I do not consent to a blood transfusion/product
Do you smoke? Yes No If the account is subject to a Workers' Compensation or Third Party claim, please bring
Any other lung, chest or breathing problems? Yes No Although this operation/procedure is carried out with all due professional care and responsibility, I understand that in some circumstances the expected
Do you drink alcohol? Yes No result may not be achieved.
Diabetes? Yes No full details of the claim including a letter from your insurance company accepting liability

MR4a Implemented Nov 2000 Revised 07/13


MSO 73657 Implemented Nov 2000 Revised 07/13
Insulin dependent Table controlled Dementia? Yes No I also understand that complications may occur with any operation/procedure and I accept the possible risks associated with this operation/procedure.
for this admission.
The possible complications, risks and benefits have been explained to me by Dr. ............................................................................................................
Has your doctor ever prescribed for you Prednisone, cortisone or other steroids?....................................................................................Yes No
PRE-ADMISSION IS AN IMPORTANT STEP. It allows us to prepare for your stay and provide
Any condition that runs in the family e.g. thalassaema, muscular dystrophy? ..........................................................................................Yes No DAY SurgerY/eNDoScoPY PATIeNTS oNlY
I understand that if I am discharged on the same day as my anaesthetic/sedation and my surgery/procedure, I should not drive a motor vehicle or you with the very best of care. Please contact our Pre-Admission nursing staff at least 72
Do you have any other health conditions not above? e.g. hormone therapy, poor teeth, arthritis? ............................................................Yes No operate machinery or potentially dangerous appliances, drink alcoholic beverages or make critical decisions for 24 hours. hours prior to your admission on (02) 8775 1101.
Are you currently taking Aspirin, Dispirin, Warfarin, clopidogel, arthritis medication? .......................................................................Yes No I also understand that I must be accompanied home by a responsible adult. EYE SuRGERY PAtIENtS ONlY:
If Yes, have you ceased or will cease these medications? Yes No When? .. ................................................................................................ * Delete as required If you have red eyes, a cold sore (herpes simplex), a cold or flu like symptoms on the day prior to surgery please contact Our office staff will also be pleased to assist you with any questions about hospital
your doctor or the hospital.
Are you aware of any past history or present infections including VRE or Staph infections (MRSA)? .........................................................Yes No .............................................................................................................................................................................. ............................................................................................................................................................ procedure, costs or hospital insurance.
SIGNATURE OF PATIENT/GUARDIAN/RELATIVE/ATTORNEY *SIGNATURE OF WITNESS *Witness to signature only
Are you currently taking antibiotics? .......................................................................................................................................................Yes No
.............................................................................................................................................................................. ............................................................................................................................................................
Date ............/............/.................... Patient's Signature: ......................................................................................
Enquiries: (02) 9797 0555

AVI
Do you have any sores or wounds?.......................................................................................................................................................Yes No DATE FULL NAME OF WITNESS
MR 4b MR 4A MR 4A
MR 4c 6 7 8 1

TSPH MR4a 8pg Admission Form.indd 1-4 14/09/13 8:27 AM