New Patient Registration Form

Dr Joseph Hockley

FRACS Vasc

Vascular & Endovascular Surgeon

New Patient Registration Form

Mrs

Miss

Last Name

First Name

Date of Birth: *

Telephone: *

Mobile Number:

Address: *

Email Address

Health Insurance Fund *Please enter N/A if uninsured.

Membership Number: *Please enter N/A if uninsured.

Does this include hospital cover for VASCULAR? *

YesNoN/A

Please check with your health fund that your level of cover includes Vascular surgery.

Medicare Number: *No spaces between numbers.

Ref Number: *Number next to your name.

Commonwealth Age Pension Number:

Expiry Date:

Veterans Affairs Card:

Colour:

GoldWhite

Workers Compensation:

Yes (please provide more details in the box to the right)No

Workers Compensation Details (Injury / Date of Injury / Case Manager / Claim ID / Case Contact):

Name of referring Doctor/Specialist: *

Name of usual GP (If not referring doctor):

Next of Kin: *

NOK Telephone: *

Reason for referral (in your own words): *

Past medical history: *

Past surgery/operations:

Other allergies (ie. antibiotics, tapes, pain medicines)? Please include reaction (what happened):

Allergy to Contrast/Dye

YesNo

If yes please specify below -

Contrast/Dye name (if known):

Current Medications (Please include dose and frequency):

Vascular Risk Factors: Please choose yes or no and complete information as required.

Heart Disease - additional info.

Diabetes

Diet controlledTablet controlledInsulin controlledUnsure

Diabetes - additional info.

High Blood Pressure

Medication controlled - (if yes, please list above in medications).

High Cholesterol

Diet controlledMedication controlled - (if yes, please list above in medications).

Smoking

Current (have smoked within last six months)Quit (Year?)

Smoking - additional info.

Stroke / TIA (ministroke)

Yes (Year?)No

Stroke / TIA - additional info.

Aneurysm

Yes (family history?)No

Aneurysm - additional info.

Leg problems

Pain with exercisePain at restUlcer / WoundOther (please specify)

Leg problems - additional info.

Emphysema / Asthma

YesNo

DVT (Blood clot)

LegPulmonary Embolism (clot to lung)

Varicose Veins

Yes (if yes please complete the questionnaire below).

Kidney Problems

YesNo

Kidney problems - additional info.

Bleeding or Clotting problems

Clotting problemsBleeding problems

Back Pain / Sciatica

Yes (surgery or treatment?)No

Back pain / Sciatic - additional info.

Scarring problems (keloid)

YesNo

Are you taking diabetic medication?

Metformin / Diformin / JanumetForxiga / Xigduo / Qtern (Dapagliflozin) / Jardiance / Jardiamet / Glyxambi (Empagliflozin)

Varicose Veins Questionnaire

Please complete this questionnaire ONLY if you have been referred for treatment of varicose veins.

In your own words, please describe the reason you are seeking treatment for your varicose veins:

Where are your varicose veins located:

Left legRight legBoth legs - which leg is worse?

Varicose veins - additional info.

Do you have a history of:

DVT (deep vein thrombosis)Keloid scarringPhelbitis (surface vein clot / SVT / STP)Inflammatory bowel disease (ulcerative colitis / Crohn's disease)

Does anyone in your family have a history of:

Clotting problems - if yes what is their relationship to you?Varicose veins - if yes what is their relationship to you?

Varicose vein history - additional info.

Do you have any of the following:

Skin thickeningUlcers / woundsSkin stainingDermatitis / Eczema ( red, itchy rash) - anklesSwelling of the legs and/or ankles - if yes, please specify area affected (eg. toes, feet, ankles etc):Restless legs or night cramps

Skin changes - additional info.

Have you used compression stockings?

Have you had previous treatment for varicose veins?

Sclerotherapy / InjectionsEndovenous laser ablationRadiofrequency ablationSurgery - Phlebectomies or tie and strip

Treatment - additional info. If yes, please specify which leg, performed by which doctor and date of procedure.

FEMALE PATIENTS

Have you been pregnant?

YesNo

Did you have problems with swollen veins whilst pregnant?

YesNo

Do you have symptoms of Pelvic Congestion Syndrome?

Pelvic ache or pain (if yes, is the pain worse with prolonged sitting or standing?)Heaviness in pelvis when standing/sitting for long periods of timePainful intercourseBladder / Bowel irritabilityAll of the above, worse since pregnancy

Do you take:

Oral HRT (hormone replacement therapy) - which one? (specify in additional info box below).Oral contraceptive pill - which one? (specify in additional info box below).No

Female patients - additional info.How many children, which HRT or contraceptive pill.

Referral Upload

Browse

Please upload your GP / Specialist referral and any relevant scan results. (Ultrasound, CT, MRI, echo etc). Only the following file types can be uploaded - .pdf, .jpg, .jpeg, .png

Participation in Audit of Cases: (Please read carefully)

Our practice is committed to maintaining the highest standards of care.

Dr Hockley is a member of the Australian and New Zealand Society of Vascular Surgery and participates in their Audit of cases. Information about you and your surgery is stored in a central database managed out of Melbourne.

The purpose of this is to identify cases performed and outcomes of surgery to ensure the highest quality of care. Personal information gathered includes name, date of birth, some medical conditions, your operation, and any complications that may occur as a result of your surgery or hospital admission.

Please indicate below if you DO OR DONOT consentfor this information to be gathered.

You can withdraw this consent at any point by contacting the rooms.

If you have any questions please speak with Dr Hockley about this.

Consent - Audit of Cases *

I give my consent to participate in Audit of Cases.I do not give my consent to participate in Audit of Cases.

Clinical Research and Trials: (Please read carefully)

Dr Hockley is the clinical lead for Vascular Surgery at the Heart and Vascular Research Institute based at Harry Perkin’s QEII.

From time to time your condition may qualify for various research studies we have running. These can range from ‘first in man’ trials to simple observational research. Some include medications and some medical devices.

Please indicate below if you DO OR DO NOT consent for this information to be gathered.

You can withdraw this consent at any point by contacting the rooms.

If you have any questions please speak with Dr Hockley about this.

Consent - Clinical Research and Trials *

I give my consent to participate in Clinical Research and Trials.I do not give my consent to participate in Clinical Research and Trials.

CONSENT: (Please read carefully and sign)

I understand that Dr Joseph Hockley complies with the Privacy Act (2001) and as part of their Privacy Policy, they are committed to protecting the privacy of individuals and their personal information. The purpose of collecting my personal information is to provide quality medical and health related services and associated account keeping. I understand I have the right to request access to my information except where access would be denied, and that Dr Joseph Hockley makes every effort to manage my information in accordance with the National Privacy Principles and keep my records up to date and accurate. I understand I may withdraw my consent for Dr Joseph Hockley to use and disclose my personal information (except when legal obligations must be met).

My signature below indicates that I have read the above and consent to:

Dr Joseph Hockley collecting, using, storing and disposing of my personal information,
The release of relevant personal information to other health professionals (e.g. Specialists etc),
The release of relevant personal information to my (prospective) employer, their authorized representative, and their insurer in the case of a work related consultation or service.

Signature (or guardian if under 16) *

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You can select to draw or type your signature.

Date signed *

I am a new patient *

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