Step 1 of 2 50% Title:*DrMrMastMrsMissMsOtherPatient Surname:* Given Names:* (as appears on Medicare Card)Preferred Name: Sex:* Male Female Patient’s Street Address:* Street Address Suburb Postcode Patient’s Mailing Address: Mailing Address Suburb Postcode (if different from above)Date of Birth: Month Day Year Contact Phone Numbers:HomeWorkMobileContact Email Address:* Medicare Number: Ref: Expiry Date: DVA Number: Gold/White Card: Gold White Expiry: Work Cover Claim Reference: Private Fund Name: Membership Number: Level/Type of Cover: Hospital & Extras Hospital Only Extra Only Uninsured This information will help your doctor to understand your problem. Please complete the form as completely as possible. If you have any questions, do not hesitate to ask your doctor.Which knee is the problem? Right Left Both When did the problem start? Have you had previous problems with your knee? Is the current problem a result of: Car Accident Work Injury Sports Injury Other Previous knee surgery? Yes No What problems are you experiencing? Please tick all that apply. Pain Stiffness Catching/locking Weakness Swelling Limited Motion Instability/dislocation Grinding/popping Clicking Quality/Severity of Pain: Throbbing Sharp Dull Aching Stabbing Burning How severe is your pain: 0 1 2 3 4 5 6 7 8 9 10 (No Pain to Severe Pain)When is the pain relieved? Nothing Rest Activity Medication Injection Physiotherapy Ice Heat Medical HistoryDo you suffer from hip problems? Yes No Do you have any back problems? Yes No Do/did you have any hear problems? Yes No Do/did you have ulcers/gastritis? Yes No Do/did you have diabetes? Yes No Do/did you have liver problems/hepatitis? Yes No Do/did you have kidney disease? Yes No Do/did you have cancer? Yes No Do/did you have blood clots? Yes No Do/did you smoke cigarettes? Yes No (if yes, how many) Do/Did you drink alcohol? Yes No (if yes, how many units per week) Do you suffer from any allergies? Yes No Do you have any drug allergies? Yes No Signature* Δ