Admission Form. Admission Date: Admission Time: Fasting Time:
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1 580 Lower North East Road Campbelltown SA 5074 Phone: (08) Facsimile: (08) Website: Admission Form Admission Date: Admission Time: Fasting Time: Please return the COMPLETED ADMISSION FORMS AT LEAST 10 DAYS PRIOR TO ADMISSION. (If posting at least 10 days prior)
2 Admission Details Admitting Doctor Admission Date Admission Type Admission Reason Patient/Client Title First Name Last Name Previous Surname Preferred Name Address Suburb State Postcode Country Phone Mobile Business Hours After Hours Address Gender Male Female Date of Birth (dd/mm/yyyy) Age years Marital Status Country of Birth Indigenous Status Australian Resident Yes No Main Cultural Identity Preferred Language Language spoken at home Do you need an Interpreter Yes No Occupation Employment Status Religion Page 1 of 10
3 Health Cover Do you have a Medicare Card? Yes No Medicare No. Reference ID Medicare Expiry Do you have a Private Health Insurance? Fund Name Yes No Membership No. Do you have a Veterans Affairs Card? Veteran Affairs No. Yes No Veteran Affairs Expiry Veteran Affairs Colour Do you have a Pension or Concession Card? Benefits Type Yes Card Expiry No Card No. Is this a Worker's Compensation or Transport Accident Claim? Yes No Claim Number Date of Incident Employer Name Insurance Company Employer Address Insurance Contact Do you have Ambulance cover? Membership Cover No. Yes No Ambulance Cover Expiry Emergency Contacts and Next of Kin Name Relationship Mobile Address Page 2 of 10
4 Medical Contacts (Doctor/Dentist/Specialist) Name Phone Practice Address Current Medications Name of Medicine Dose Frequency Medication History Do you administer the medication yourself? Do you usually use a dose administration aid (webster pack or dosette)? Do you take any anti-coagulant or blood thinning medications? E.g. Warfarin/Coumadin/Plavix/Iscover/Aspirin Has this been stopped prior to surgery? When was the medication last taken? Do you use recreational drugs? If Yes, what type and how much? Do you drink alcohol? If Yes, how many standard drinks each day? Do you have a local community pharmacy? Pharmacy Name Contact number Page 3 of 10
5 Current Allergies Allergy Allergic Reaction Discharge Planning Are you expecting to return to your current residential address directly from hospital? If No, please specify plans. Do you live alone? Additional Comments Do you have family support on discharge? Additional Comments Do you care for others at home? If Yes, who is caring for them? Have you been assessed by the Aged Care Assessment Team (ACAT)? Date of Assessment? Do you live in residential aged care? E.g. Nursing Home / Hostel Residential Aged Care Name Contact number Page 4 of 10
6 Has anyone been appointed as your Power of Attorney and / or Enduring Guardian? Name Contact number Do you have an Advanced Medical directive? If Yes, please bring it to hospital with you. Do you use a walking stick / frame? Do you use a wheel chair? Do you use assistance to walk? Do you have steps / stairs at your home? Do you have handrails in the bathroom at your home? Do you have a shower over the bath at your home? Day Surgery Only Are you having a Day Procedure? Have you organised an escort and transport following your discharge? Name of person taking you home? Contact number We would like to contact you following the procedure. What is the best contact number? Surgical History Have you had any major operations? List all operations and the year you had them. Page 5 of 10
7 Medical History What is your weight? Kg What is your height? Cm What is your BMI? (Body Mass Index) (If Known) Have you ever had anaesthetics before? Have you ever had a spinal or epidural anaesthetic before? Have you ever had any problems with anaesthetics? If Yes, describe. Do you have any heart problems? (Irregular heart rate, murmur, etc.) If Yes, describe. Have you ever had a heart attack? If Yes, when? Have you ever had a bypass surgery? (bypass, valve replacement, stent) If Yes, describe. Do you have a pacemaker? Do you have an implanted defibrillator? Do you suffer from angina? Page 6 of 10
8 Do you use any of the following? (GTN Patch, Sublingual Spray or Tablets) If Yes, how often and date last used? Do you get shortness of breath, chest pain or palpitations after exercise or climbing stairs? If Yes, describe. Have you ever had blood pressure problems? (Low/High) If Yes, which one? Have you ever had a TIA/Stroke? If Yes, when and describe any ongoing problems. Do you have any bleeding / clotting / blood disorders? Have you ever had a blood transfusion? Have you ever had any reactions to a blood transfusion? Do you have any previous history of blood clots in your lungs (PE), legs or arms? If Yes, which year? Have you ever been diagnosed with cancer? If Yes, which type? Do you have any lung or chest conditions? (Asthma, bronchitis, emphysema) Page 7 of 10
9 Have you had a cold or flu in the past 2 weeks? Do you have diabetes? How do you manage it? (diet controlled, insulin or tablet) Do you require any special dietary needs? If Yes, please describe? Do you have liver disease? Do you have any gastric problems (gastric banding, reflux) Do you have any bowel problems? (diarrhoea, constipation, incontinence, diverticulosis/stomas) Do you have kidney problems? Do you have any bladder problems? (incontinence, frequency, frequent infection) Do you have mobility problems? (arthritis, back pain, leg weakness) Page 8 of 10
10 Do you suffer from depression or anxiety? Have you experienced fainting or dizziness in the past 12 months? Have you had any fits, convulsions or blackouts? (epilepsy) Do you have any problems with your vision? (limited, cataract, glaucoma) Do you wear glasses/contact lenses? Do you require assistance to shower, dress, get in/out of bed/chair? Do you have any hearing problems or hearing aids? Have you had any falls in the past 12 months? Do you have lymphoedema / existing wounds / pressure area (ulcer, broken skin or reddened skin due to friction or pressure) Have you ever had a multi-resistant organism infection (MRSA, Golden Staph, VRE - Please speak to the admission nurse if unsure) Do you have or have you had any infectious diseases? (Hepatitis A, B, C) Page 9 of 10
11 Do you have any problem sleeping? Do you have sleep apnoea? Do you use a CPAP machine? (If Yes, please bring CPAP machine with you) Please describe any other sleeping problems. Maternity Patients Are you pregnant? Expected Date of Delivery? Complications of this pregnancy? Relevant Family History: Investigations: Have you had an ultrasound? Have you had Amniocentesis? Nursing : This information has been reviewed and discussed with patient by: Signature: Designation: Print Name: Date: Page 10 of 10
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