Dr Kieran McCaffrey

Obstetrics

Gynaecology

About Me

New Patient Form

Obstetrics

Gynaecology

About Me

New Patient Form

Name

Date of Birth

Occupation

Full Address, City & Postcode

Mobile Phone

Home Phone

Emergency Contact Name

Emergency Contact Number

REFERRING GP/SPECIALIST DETAILS:

WHERE DID YOU HEAR ABOUT DR MCCAFFREY?

MEDICARE NUMBER

MEDICARE REFERENCE NUMBER

DO YOU HAVE PRIVATE HEALTH COVER?

LEVEL OF PRIVATE COVER:

PRIVATE FUND

PRIVATE FUND MEMBER NUMBER / ID

DO YOU HAVE ANY MEDICAL CONDITIONS?

ANY PREVIOUS SURGERIES?

ANY FAMILY HISTORY OF MEDICAL CONDITIONS?

LIST OF CURRENT MEDICATIONS OR SUPPLEMENTS?

ANY KNOWN ALLERGIES?

WHEN WAS YOUR MOST RECENT CERVICAL SCREENING TEST (PAP SMEAR)?

EVER HAD A MAMMOGRAM / WHAT YEAR / RESULT NORMAL OR ABNORMAL?

HAVE YOU EVER BEEN PREGNANT? (IF SO, HOW MANY PREGNANCIES? AND WERE THEY VAGINAL OR BY CAESAREAN SECTION?)

HAVE YOU HAD AN ECTOPIC PREGNANCY? (IF SO, HOW MANY)

HAVE YOU HAD A MISCARRIAGE? (IF SO, HOW MANY)

HAVE YOU HAD A TERMINATION OF PREGNANCY? (IF SO, HOW MANY)

*FOR OBSTETRIC PATIENTS - PLEASE PROVIDE THE FOLLOWING ADDITIONAL BIRTH DETAILS OF YOUR CHILD: NAME / SEX / DOB / HOSPITAL / GESTATION / BIRTH WEIGHT / MODE OF DELIVERY (NORMAL VAGINAL, VACUUM, FORCEPS, OR CAESAREAN SECTION)

BIRTH # 1

BIRTH # 2

BIRTH # 3

BIRTH # 4

ANY PREGNANCY COMPLICATIONS?

To comply with the Privacy Act 2001, all patients need to provide consent for the following important aspects of their medical care:

I agree that relevant information may be obtained rom other medical practitioners, such as GPs and Specialists, other health care providers, pathologists, hospital and day surgery units as necessary
I agree that Dr McCaffrey may discuss my medical history, diagnosis and management with my general practitioner and other relevant medical specialists in relation to my medical management
I agree that Dr McCaffrey's database may be used in an anonymous fashion for medical research purposes
l agree that for unpaid accounts requiring a collection agency, 30% of my invoice will be added to cover these expenses
I acknowledge that this practice at times uses medical scribing Al software to assist in note taking and dictation