PATIENT PRE-ADMISSION QUESTIONNAIRE

Please fill out all mandatory fields marked with an asterisk *

PATIENT PROFILE

Title

Firstname*

Lastname*

Sex

DOB*

Day

Month

Year

Age

Phone

Mobile*

Please enter 10 digital number without spaces (e.g. 0499999999).

Home

Work

Occupation

Marital

Country of Birth*

Language spoken at home

Are you a permanent resident of Australia?

Yes No

Do you identify as*

ADDRESS

Street Address

Address

Suburb

State

Postcode

Postal Address

Use street address?

Yes No

Address

Suburb

State

Postcode

ENTITLEMENTS

Medicare

Medicare Card No (10 digit card number e.g. 1234567890)

Expiry Date (e.g. 01/2099)

Reference No (the number next to your name)

Pension Card

Pension Card No

Expiry Date (e.g. 01/2099)

DVA

DVA File Number

Expiry Date (e.g. 01/2099)

Card Colour

White Gold

PRIVATE HEALTH INSURANCE DETAILS

Private Insurance Fund Name

Please Specify

Membership Number

Level of cover if known

Hospital excess if known

Have you paid your excess this calendar year?

Yes No

If No, the excess should be paid on the day of your procedure or admission. (We accept cash, EFTPOS/credit cards and bank cheques).

GENERAL PRACTITIONER

Please enter details of your GP

Name

Phone

Address

Postcode

NEXT OF KIN / EMERGENCY CONTACT

Name

Phone

Address

Relationship

SUBSTITUTE DECISION MAKER IF DIFFERENT TO ABOVE

Name

Phone

Home

Mobile

Upload Attachments

Id	Document Type	File name

ABOUT YOUR PERSONAL HEALTH INFORMATION

We acknowledge our obligations to you under the Privacy Amendment (Private Sector) Act 2000 and the Health Records and Information Privacy Act 2002. Personal health information we collect from you will be used primarily to ensure that you recieve optimal care but may also be used for other purposes. Personal health information is released under legislation to the State Health Authority, health funds and the Private Hospital Data Bureau.

PERSONAL DETAILS CONSENT

I hereby consent to the collection and use of my personal health information for the purpose of my care and wellbeing and in accordance with the reporting requirements under legisations.*

Person signing: Patient Patient Representative Assisted by TSH staff

Signature*:
(Please use mouse or stylus to sign below.)

Relationship to patient

Marketing & Fundraising: Several times a year The Skin Hospital sends out newsletters and provides updates on fundraising activities. If you do not wish to receive these marketing communications please tick the box. Please note that only your name, address and email will be used for this, all other personal details remain confidential. The Skin Hospital does not share these lists with any other organisation.

MEDICAL HISTORY

GENERAL INFORMATION

	Yes/No
Are you pregnant?
How many weeks?
Do you have any religious / cultural needs?
Details
Do you have an Advance Care Directive (AHD)? (if yes, please bring in a copy)
Details
Do you have a CURRENT and ACTIVE legal guardianship order in place for another person to consent on your behalf to medical procedures or treatments?
You must bring a copy of the documents with you to your appointment.

ALLERGIES

Do you have any allergies (medicines, sticking plaster, iodine, latex, food etc.)?

Yes Nil Known

Allergy/Reaction	Allergy/Reaction

SURGICAL/MEDICAL HISTORY

List and date previous surgery, gastroscopy & colonscopy or where procedure undertaken

What is your weight (kg)

What is your height (cm)

BMI

CURRENT MEDICATIONS TAKEN (BRING MEDICATION WITH YOU WHENEVER YOU COME TO HOSPITAL)

Please list all medications below including complimentary medicines like vitamins

I am on blood thinners such as: Aspirin Warfarin Xarelto Plavix/Iscover Other

INR

Last dose taken

Has your doctor asked you to cease this medication?

Yes No

Details

Please call your doctor to discuss.

Drug Name	Dose	Frequency

HEALTH QUESTIONAIRE

Do you currently have, or have you had any of the following	Yes/No
Have you, or any of your blood relatives ever had a problem with anaesthetic
Details
Difficulty swallowing, opening your mouth or moving your neck
Details
Difficulty when you lay flat on your back?
Details
Difficulty walking up more than 2 flights of stairs
Details
Dentures
Upper only Lower only Both upper & lower
Loose or chipped teeth
Details
High blood pressure
Is it controlled on medication? Yes No
Details
Angina, Arrhythmias or palpitations
Details
Heart attack
When and what was the outcome
Heart surgery / pacemaker / defibrillator inserted
Details
Other heart problem
Details
Heartburn or acid reflux
Details
Liver disease / hepatitis / jaundice
Details
Kidney disease
Are you on Dialysis? Yes No
Previous blood clots in the legs or lungs
Details
Bleeding / bruising disorders
Details
Anaemia / Previous blood transfusion
Any issues?
Diabetes
Diet Controlled Tablets Insulin Usual blood sugar level
Asthma
How frequent are the attacks? Daily Weekly Monthly Yearly
COPD / Emphysema / Lung disease
Details
Sleep apnoea
CPAP machine? Yes No
Epilepsy or fits
How frequent are the attacks? Daily Weekly Monthly Yearly
Arthritis
Details
Do you currently smoke or vape?
When?
Have you quit smoking or vaping
When?
Do you drink alcohol?
How often and how much?
Do you take recreational (party) drugs?
What do you take and how often?
Do you suffer from anxiety, depression or emotional disorders?
Details
Have you been diagnosed with Alzheimer’s or dementia?
Details
Have you had any recent changes to your behaviour or thinking
Details
Stroke or TIA
When?
Have you had an episode of delirium or confusion after surgery?
What are the warning signs
Falls history: Have you had any falls in the last 12 months?
How many?
Do you have a fear of falling?
More information please
Do you use walking aids?
Person Assisted Walking aide Wheelchair
Skin integrity: Do you have skin problems such as sores, skin tears, bruises, blisters, rashes, dermatitis or pressure sores?
Details
Infection History:
Have you had COVID-19?
Date of your most recent infection
Have you ever been placed in a private room during your hospital stay due to an infection?
Have you ever been infected or colonised with a multi-resistant organism? MRSA VRE CRE/CPE MRPA ESBL Do you have a virus such as Hep B Hep C HIV NO
Have you been In hospital in the last 4 weeks?
Details
Have you been exposed an infectious disease in the last 2 weeks?
More information
Do you currently have an infectious disease?
More information
Have you travelled overseas in the last 6 weeks?
Where to
Have you been in an overseas hospital in the last 12 months?

Other medical conditions or disabilities not already mentioned
Details
Is there anything else you would like us to know so we can assist you on the day of surgery?
Please let us know how we can help you during your admission

PLANNING FOR YOUR DISCHARGE

How are you getting home: Private Car Taxi DVA Public Transport

	Yes/No
Do you live alone?
Who will stay with you overnight?
Details
Do you have care responsibilities for others?
When

Who is picking you up?

Name

Relationship

Mobile

SIGNATURE

Signature:
(Please use mouse or stylus to sign below.)

GENERAL CONSENT FORM

Consent Detail

BACKGROUND

The Skin Hospital is a specialised medical organisation dedicated to providing high quality services in the areas of dermatology and dermatopathology.

The Skin Hospital is a major training centre for future specialist dermatologists and funds approximately one fifth of the training positions available for dermatology registrars in NSW. The dermatology registrars are specialists in training. They are medical graduates who have entered an advanced post-graduate training scheme in dermatology which extends over a five-year period. At the end of that time, they can qualify as specialist dermatologists.

Our practice is affiliated with the University of Sydney, the University of NSW, St Vincent’s Hospital, Westmead Hospital and The Children’s Hospital, Westmead.

HOW ARE PATIENTS AFFECTED BY THE TEACHING AND RESEARCH ACTIVITIES CONDUCTED AT THE SKIN HOSPITAL?

Teaching

Trainee dermatologists, other doctors, medical students, and nursing students sometimes attend clinics at The Skin Hospital for educational purposes. Medical records of consenting patients may be used for educational activities. If patients have any objection to other doctors or students being in the clinic room at the time of their consultation they may, of course, inform their attending dermatologist in which case those other doctors or students will vacate the consultation.

Clinical trials

Clinical trials for new treatments are carried out at The Skin Hospital. Patients may be asked if they are willing to participate in trials related to treatment of their skin condition. The nature of the trial is fully discussed and there is no obligation to participate. Patient medical records may be used to determine trial eligibility for those consenting to be contacted for trials. Non-participation in clinical trials will not affect the clinical care of a patient at The Skin Hospital.

Research

The Skin Hospital Research unit is one of Australia’s leading providers of quality dermatology clinical research. Our research projects investigate better patient care methodologies and we conduct research using medical records of consenting patients. To learn more about our projects and research publications go to www.skinhospital.edu.au/research/

Use of photographs and patient records

In certain circumstances, patients have photographs taken and these along with the patient’s medical records may be used for scientific research and education purposes. We will take reasonable steps to ensure that the patient’s identity and privacy is protected.

If the research or educational activity involves use of patient information with identifying markers that could reveal patient identity to third parties, then such use will not be undertaken without obtaining additional consent for such use. In this case, individuals will be contacted by The Skin Hospital to obtain the consent of the patient for such use. The collection use and disclosure of these photographs is governed by The Skin Hospital’s Clinical Images Policy available at www.skinhospital.edu.au, with which all staff are required to comply.

You can withdraw consent for the use of your photographs and medical records for education and/or research at any time. This can be discussed further with the staff at the reception.

OUR FEES AND BILLING POLICY

The Skin Hospital has set its fees at a level we regard as fair and reasonable.
We do not bulk bill, but consideration is given to disadvantaged patients.
There is a Medicare rebate claimable for people with referrals.

FEES FOR MEDICAL SERVICES

The fee charged by doctors at The Skin Hospital is determined by the individual doctor. Generally, the Australian Medical Association (AMA) fees are used as a guide.
Cosmetic services in general do not attract a Medicare rebate. The cost for these services should be discussed with your doctor or other qualified staff at The Skin Hospital before proceeding.
Surgical procedures may also attract a facility fee in addition to the doctor’s fee. This covers the cost of consumables, e.g., dressings, and goes towards maintaining the facility and equipment in good order.
Small, non-invasive procedures such as cryotherapy incur an additional fee on top of the consultation.

Payment is required at the time of your consultation. Payments can be made by cash, cheque, or credit card (Debit card, Mastercard, Visa). We can submit an online claim to Medicare for you to claim your rebate.

FEES FOR PATHOLOGY SERVICES

If a specimen of skin is removed or other samples collected, a separate account will be sent to you later from either The Skin Hospital laboratory or from another Pathology provider. This fee is for the processing and reporting of your specimen or specimens.
Sometimes more than one pathology test is performed, and you may receive more than one bill for pathology.
Some pathology tests do not attract a Medicare benefit, but these are not often required, and your doctor can discuss any costs with you.

If you have any questions regarding fees, please discuss your concerns with your doctor or the staff at the reception or nursing desks of The Skin Hospital.

ABOUT YOUR PERSONAL HEALTH INFORMATION

The Skin Hospital is committed to protecting your privacy. We comply with our obligations under the Privacy Act 1988 (Cth) (“Privacy Act”), the Australian Privacy Principles (“APPs") and the Health Records and Information Privacy Act 2002 (NSW). By providing your personal and sensitive information to us voluntarily, you agree that it will be used and disclosed in accordance with our Privacy Policy.

If you choose not to provide some or all of the requested personal information, this may impact our ability to effectively provide you with health care services at the highest possible standard. We only disclose your personal information as described in our Privacy Policy, and you consent to us disclosing your personal information on that basis. We may disclose your personal information to third party service providers who help us to provide our services or to such other organisations who we are legally obliged to provide your information to. This may include Medicare Australia, private health insurers, the State Health Authority, Private Hospital Data Bureau and the Department of Veterans Affairs.

You have a right to request that the personal information we hold about you is updated, corrected or deleted. For more information on how you can access your personal information or contact us with any questions, concerns or privacy related complaints, please see our Privacy Policy which is available at www.skinhospital.edu.au/privacy-policy/ or contact us at privacyofficer@skinhospital.edu.au.

I, have read the above information and understand that:

The Skin Hospital is a training facility for dermatology registrars, other doctors, and medical students/s.
I understand that photographs will be kept in the medical record file and for use outside of the hospital a separate consent will be obtained from me.
Payment of consultation charges and fees incurred for additional procedures are my responsibility. I am aware that if I have any minor procedures performed (e.g. cryotherapy or biopsies etc), this will incur an additional charge payable on the day.
If a skin specimen or other sample is taken (e.g. biopsy, excision etc), I will receive a separate invoice for the pathology in the mail and that this invoice remains separate from the doctor's fee that I paid at the time of the consultation.

I provide consent for the following (please tick the applicable box):

To use my medical records for research purposes

Yes No

To use my medical records for education purposes

Yes No

To use my medical records for quality improvement activities

Yes No

To be contacted for suitable clinical trials or research participation

Yes No

Signature:
(Please use mouse or stylus to sign below.)

Your support of The Skin Hospital is greatly appreciated.

The Skin Hospital is a registered charity and is an independent, self-funded organisation. The Skin Hospital is a not-for-profit organisation that seeks to earn sufficient income to meet the costs of all its activities, without requiring funding from the public sector.

If you would like to help support this great organisation, donations are tax deductible and gratefully received.