First Consult Form | Dr Chow Chow

FIRST CONSULTATION FORM

Thank you for contacting DR CHOW CHOW. To get you prepared for your first appointment, we will need some background information on you, your pain and how it has affected you. The information you provide will help to assess your pain and to allow you to receive the excellent care we can offer.

YOUR PERSONAL DETAILS

First Name

Last Name

Email Address

Residential Address

Contact Number

Date of Birth

Medicare & Reference No.

Expiry Date

Concession Card No.

Expiry Date

DVA No.

DVA Card Colour

Private Insurer Name

Insurer No.

General Practitioner (GP) Information

PAIN HISTORY

Location of your pain.

Describe your pain.

Tell us the story of your pain.

Medical History

Current medications

List pain treatments have you tried and experienced side effects.

BRIEF PAIN INVENTORY
0 - "No Pain"; 10 - "Pain As Bad As You Can Imagine
0 - "Does Not Interfere"; 10 - "Completely Interferes"

HOW DOES YOUR PAIN AFFECTING YOUR EMOTION?

Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

0 - Did not apply to me at all - NEVER
1 - Applied to me to some degree, or some of the time - SOMETIMES
2 - Applied to me to a considerable degree, or a good part of time - OFTEN
3 - Applied to me very much, or most of the time - ALMOST ALWAYS

1. I found it hard to wind down

0 1 2 3

2. I was aware of dryness of my mouth

0 1 2 3

3. I couldn’t seem to experience any positive feeling at all

0 1 2 3

4. I experienced breathing difficulty (e.g. excessively rapid breathing, breathlessness in the absence of physical exertion)

0 1 2 3

5. I found it difficult to work up the initiative to do things

0 1 2 3

6. I tended to over-react to situations

0 1 2 3

7. I experienced trembling (e.g. in the hands)

0 1 2 3

8. I felt that I was using a lot of nervous energy

0 1 2 3

9. I was worried about situations in which I might panic and make a fool of myself

0 1 2 3

10. I felt that I had nothing to look forward to

0 1 2 3

11. I found myself getting agitated

0 1 2 3

12. I found it difficult to relax

0 1 2 3

13. I felt down-hearted and blue

0 1 2 3

14. I was intolerant of anything that kept me from getting on with what I was doing

0 1 2 3

15. I felt I was close to panic

0 1 2 3

16. I was unable to become enthusiastic about anything

0 1 2 3

17. I felt I wasn’t worth much as a person

0 1 2 3

18. I felt that I was rather touchy

0 1 2 3

19. I was aware of the action of my heart in the absence of physical exertion (e.g. sense of heart rate increase, heart missing a beat)

0 1 2 3

20. I felt scared without any good reason

0 1 2 3

21. I felt that life was meaningless

0 1 2 3

IS YOUR PAIN INTRUDING YOUR THOUGHTS?

Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic.

Had nightmares about it or thought about it when you did not want to?

YES NO

Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

YES NO

Were constantly on guard, watchful or easily startled?

YES NO

Felt numb or detached from others, activities, or your surroundings?

YES NO

Felt guilty or unable to stop blaming yourself or others for the event or any problems the event may have caused?

YES NO

We are interested in the types of thoughts and feeling that you have when you are in pain. Using the scale, please indicate the degree to which you have these thoughts and feelings when you are experiencing pain.

0 - Not at all
1 - To a slight degree
2 - To a moderate degree
3 - To a great degree
4 - All the time

Please rate how confident you are that you can do the following things at present, despite the pain.

0 - Not at all confident
6 - Completely confident

HOW DOES YOUR PAIN INTERFERE WITH YOUR DAILY ACTIVITIES?

Dressing

Feeding

Physical Ambulation

Toilet

Bathing or Showering

Shopping

Housekeeping

Ability to Handle Finances

Food Preparation

Transportation

How Many Hour Do You Sleep For?

ADDITIONAL INFORMATION

Please write any additional information that you would like to address or discuss

In compliance with best practices for transparency and informed consent, we strongly recommend that you take the time to thoroughly review our Terms and Conditions as well as our Privacy Policy. Doing so will offer you a comprehensive understanding of the contractual and privacy frameworks governing our interactions and services. We consider these documents instrumental in establishing a mutually beneficial relationship grounded in clarity and trust.

By checking this box, you are agreeing to our Terms and Conditions and Privacy Statement.

47370

POTTS POINT ● CHATSWOOD ● SYDNEY CBD ● CONCORD

Serving community at Darlinghurst, Surry Hills, Potts Point, King Cross, Elizabeth Bay, Rushcutters Bay, Edgecliff, Paddington, Woollahra, Double Bay, Point Piper, Bellevue Hill, Bondi, Vaucluse, Woolloomooloo, Sydney Central Business District (CBD), Haymarket, The Rocks, Walsh Bay, Barangaroo, Dawes Point, Millers Point, Ultimo, Chippendale, Darlington, Pyrmont, Alexandria, Eveleigh, Beaconsfield, Redfern, Glebe, Forest Lodge, Concord, Mortlake, Cabaret, Breakfast Point, Strathfield, Burwood, Croydon, Rhodes, Liberty Grove, Homebush, Wentworth Point, Sydney Olympic Park, Newington, Ryde, Melrose Park, Eastwood, Epping, Gladesville, Hunters Hill, Chatswood, Lane Cove, Artarmon, Roseville, Lindfield, St Leonards, Cammeray, North Sydney, Neutral Bay, Cremorne, Willoughby, Northbridge, Mosman, Killara, Gordon, Pymble, Macquarie Park

Here’s An Easy Way to Show You Care

Thank you for your kind referral, please also fax us a copy of patient’s health summary with their current medication and medical history at (02) 8088 7877

PO Box 18 Roslyn Street, Potts Point 2011 NSW
Phone 02 8866 1393
Fax 02 8088 7877
info@drchowchow.com
Healthlink: tzechowc

DR CHOW CHOW

Thank you for submitting the consultation form. We look forward to seeing you at your appointment.

If you would like to upload further information or talk to one of us, please contact

FIRST CONSULTATION FORM

POTTS POINT ● CHATSWOOD ● SYDNEY CBD ● CONCORD

DR CHOW CHOW

info@drchowchow.com 02 8866 1393

info@drchowchow.com
02 8866 1393