Eastern Suburbs Urology

Patient Registration Form

New Patient Information Form

Personal Details

Do you have a different Postal Address?

Medicare/ Health Fund/ DVA Details

Do you have a pension card?
Do You have a DVA card?
Do you have private health insurance?

Next of Kin

GP & Specialists Details

Allergies

Medications

Medical Conditions

Medical Conditions

Previous Surgery

International Prostate Symptom Score (I-PSS)

I-PSS 1
1. Incomplete Emptying
Over the past month, how often have you had the sensation of not emptying your bladder?
2. Frequency
Over the past month, how often have you had to urinate less than every two hours?
3. Intermittency
Over the past month, how often have you found you stopped and started again several times when you urinated?
4. Urgency
Over the past month, how often have you found it difficult to postpone urination?
5. Weak Stream
Over the past month, how often have you had to strain to start urination?
6. Straining
Over the past month, how often have you had to strain to start urination?
7. Nocturia
Over the past month, how many times did you typically get up at night to urinate?
7. Nocturia
Over the past month, how many times did you typically get up at night to urinate?

Total I-PSS Score

Quality of Life Due to Urinary Symptoms
If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?
(1) Delighted
(2) Pleased
(3) Mostly Satisfied
(4) Mixed
(5) Mostly Dissatisfied
(6) Unhappy
(7) Terrible
Straining
Over the past month, how often have you had to strain to start urination?

Upload Referral and Other Documents

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Consent

Consent Form for Collection and Use of Health Information

As a patient of our medical practice, we require you to provide us with your personal details and a full medical history,so that we may properly assess,diagnose,treatand be proactive in your health care needs.
We require your consent to collect personal information about you and to use the information you provide in the following ways. Please read this consent form carefully, and sign were indicated below.
* Administrative purposes in running our medical practice.
* Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
* Disclosure to others involved in your healthcare including treating doctors and specialists outside
this medical practice. This may occur though referral to other doctors, or for medical tests and in the reports or results returned to us following referrals.
* Disclosure to other doctors in the practice, locums etc. attached to the practice for the purpose of patient care and teaching.
* To comply with any legislative or regulatory requirements e.g. notifiable diseases.
* For reminder letters which may be sent to you regarding your health care and management. 
You can decline to have your health information used in all or some of the ways outlined above but it may influence our ability to manage your health care to provide the best outcome for you.

Consent Options