Online Admission Form - Victorian Gut Centre

We request that you complete the online admission form at least a week prior to your procedure.

To assist you with this process, please have the following information at hand:

Admitting doctor, admission date, procedure date and procedure (if known)
Details of referring GP
Emergency contact details
Funding details (e.g. Private Health Insurance, DVA, WorkCover etc)
Medicare card, concession card(s), Ambulance Membership card and List of medication(s)

1General Information

2Medicare, Health fund

3Health Questionnaire

4Current Medication

5Surgical History

6Declaration

GENERAL INFORMATION

How did you hear about us?(Required)

Specialist/Surgeon

Internet

Friend/Relative

Previous Patient

Have you had a consult with a gastroenterologist or surgeon in the last 30 days?(Required)

Yes

Planned procedure/s:(Required)

Gastroscopy

Colonoscopy

Flexible Sigmoidoscopy

Iron Infusion

Name:(Required)

Prefix First Middle Last

Preferred Name(Required)

Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date of Birth:(Required)

DD slash MM slash YYYY

Email:

Height (cm):(Required)

Age:(Required)

Mobile Phone:(Required)

Weight (Kg):(Required)

Country of Birth:(Required)

Home Phone:(Required)

BMI(Required)

Pronouns:(Required)

She/her

He/him

They/them

By name

Other

Gender:(Required)

Female

Male

Non binary

Prefer not to say

Other

Sex at birth:(Required)

Female

Male

Other

Are you of Aboriginal or Torres Strait Islander Origin?(Required)

Yes, Aboriginal

Yes, Torres Strait Islander

Yes, Both Aboriginal and Torres Strait Islander

Decline to Answer

Do you have any religious/cultural needs?(Required)

Yes

If yes, specify:(Required)

Do you need an interpreter?(Required)

Yes

Options(Required)

Family to interpret

Professional interpreter

Preferred language:(Required)

(Costs apply if no Medicare)

Referring doctor’s name:(Required)

Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone:(Required)

MEDICARE, HEALTH FUND AND OTHERS

Do you have Medicare?

Yes

Medicare Number:(Required)

No. In Front of Name:(Required)

Expiry Date:(Required)

Do you want to upload to MHR?

Yes

Individual Health Identifier for My Health Record (MHR):(Required)

Private Health Insurance:(Required)

Yes

Fund Name:(Required)

Membership No:(Required)

Are you currently an in-patient in any hospital?(Required)

Yes

Any excess paid in the last 12 months?(Required)

Yes

Excess or Co-payment:(Required)

Department Of Veterans Affair (DVA):(Required)

Yes

DVA Card Number:(Required)

Card Colour:(Required)

Gold

White

Is this a Workcover or TAC:(Required)

Yes

Workcover or TAC approval number:(Required)

ALL PATIENTS RECEIVING SEDATION MUST HAVE A RESPONSIBLE ADULT TO ACCOMPANY THEM HOME AND STAY WITH THEM AT HOME OVERNIGHT

CERTIFICATE/S(Required)

Medical certificate

Carer certificate

Not Applicable

Pick-up person

Name(Required)

Relationship(Required)

Contact no.(Required)

Staying with you at home after discharge

Name(Required)

Relationship(Required)

Contact no.(Required)

Next of Kin/Emergency Contact

Name(Required)

Relationship(Required)

Contact no.(Required)

HEALTH QUESTIONNAIRE – DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING CONDITIONS?

IF YES, PLEASE PROVIDE FURTHER INFORMATION

Blood pressure(Required)

Yes

Blood pressure(Required)

High

Low

Is it controlled with medication?(Required)

Heart attack(Required)

Yes

When?(Required)

Arrhythmia or irregular heartbeat(Required)

Yes

Resolved?(Required)

Is it controlled with medication?(Required)

Angina or chest pain

Yes

How frequently?(Required)

Heart Surgery / Pacemaker / Defibrillator / Stents(Required)

Yes

Tick if applicable:(Required)

Heart Surgery

Pacemaker

Defibrillator

Stents

Last date of check up with cardiologist?(Required)

DD slash MM slash YYYY

Other heart problems(Required)

Yes

If yes, specify(Required)

Asthma(Required)

Yes

Is it controlled with medication?(Required)

**PLEASE BRING YOUR PUFFER**

When was the last asthma attack?(Required)

Other lung issues or shortness of breath(Required)

Yes

Specify(Required)

Difficulty walking up more than two flights of stairs(Required)

Yes

What stops you from walking further?(Required)

Sleep apnoea(Required)

Yes

Do you use a CPAP machine?(Required)

Diabetes(Required)

Yes

Type:(Required)

Type 1

Type 2

Tick if applicable:(Required)

Diet controlled

Tablets

Insulin

Thyroid problems(Required)

Yes

Specify(Required)

Stomach problems(Required)

Yes

Tick if applicable:(Required)

Hiatus hernia

Reflux

Ulcer

Heartburn

Other

Bowel problems(Required)

Yes

Tick if applicable:(Required)

Crohn’s

Colitis

Stoma

Other

Liver disease(Required)

Yes

Specify(Required)

Weight loss surgery(Required)

Yes

Details(Required)

Kidney disease(Required)

Yes

Tick if applicable:(Required)

Dialysis

Renal Impairment

Other

Bladder problems(Required)

Yes

Bladder problems(Required)

Incontinence

Urinary Retention

Stoma

Other

Blood clots(Required)

Yes

Blood clots in the(Required)

Legs

Lungs

Stroke

When?(Required)

Resolved?(Required)

Blood disorders(Required)

Yes

Blood disorders(Required)

Anaemia

Low Iron

Bruising or bleeding tendency

Cancer(Required)

Yes

Location and treatment received:(Required)

Arthritis(Required)

Yes

Type(Required)

Rheumatoid

Osteo

Back or neck injury or other problems(Required)

Yes

Tick if applicable:(Required)

Back

Neck injury

Other

Do you have any limitation in neck movement?(Required)

Yes

Can you tolerate laying on your left side?(Required)

Yes

Difficulty swallowing or opening your mouth(Required)

Yes

Specify(Required)

Epilepsy or Seizures (Fits)(Required)

Yes

Tick if applicable:(Required)

Epilepsy

Seizures (Fits)

When?

Blackouts / Dizziness / Balance problems(Required)

Yes

Tick if applicable:(Required)

Blackouts

Dizziness

Balance problems

Specify(Required)

Memory loss / Dementia(Required)

Yes

Tick if applicable:(Required)

Short term memory loss

Dementia

Specify(Required)

Visual condition(Required)

Yes

Tick if applicable:(Required)

Glasses

Contact Lenses

Other

Hearing condition(Required)

Yes

Tick if applicable:(Required)

Hearing Aids

Other

Dental condition(Required)

Yes

Dental prosthetics:(Required)

Dentures

Caps

Crowns

Implants

Recent dental treatment

Loose/chipped tooth

Lymphoedema (swelling in arms or legs)(Required)

Yes

Location:(Required)

Other medical conditions or disabilities not already mentioned(Required)

Yes

Specify:(Required)

Anxiety / Depression / Other mental conditions(Required)

Yes

Do you suffer from(Required)

Anxiety

Depression

Other mental conditions

Specify:(Required)

Do you Smoke or Vape(Required)

Yes

Do you(Required)

Smoke

Vape

How many cigarettes per day?(Required)

PLEASE STOP SMOKING 2 DAYS BEFORE YOUR PROCEDURE

Do you use recreational drugs?(Required)

Yes

What do you take and how often?(Required)

PLEASE DO NOT TAKE 2 DAYS BEFORE YOUR PROCEDURE

Do you drink alcohol?(Required)

Yes

How often?(Required)

Have you or a family member ever had problems with anaesthetics?(Required)

Yes

Who(Required)

You

Family member

Tick if applicable:(Required)

Nausea or vomiting

Malignant Hyperthermia

Other

Have you had an episode of delirium or aggression after anaesthetics?(Required)

Yes

Specify:(Required)

Could you be pregnant?(Required)

Yes

Do you have an advanced care directive or treatment limiting order?(Required)

Yes

This is a document that lists your preferences for future medical treatment i.e. consenting to or refusing specific types of treatment, should you lose decision-making capacity. If yes, please attach a copy to this form.

Upload File(Required)

Max. file size: 128 MB.

Do you have any multi resistant infections?(Required)

Yes

Tick if applicable:(Required)

MRSA

VRE

CRE

C. Difficile

Other

Is it:(Required)

Active

Inactive

Do you have/have you had COVID-19?(Required)

Yes

Symptoms?(Required)

When?(Required)

Did you receive treatment in hospital?(Required)

Fully recovered?(Required)

Have you been unwell in the past 2 weeks?(Required)

Yes

Details:

Have you or a family member been recently exposed to a communicable disease?(Required)

Yes

Who(Required)

You

Family member

Have you been unwell in the past 2 weeks?(Required)

Shingles

Chickenpox

Measles

Whooping cough

Other

Have you returned from an overseas trip in the past 30 days?(Required)

Yes

Country:(Required)

Have you been unwell since return?(Required)

Have you been hospitalised overseas or in another facility in the past 12 months?(Required)

Yes

Hospital:(Required)

Reason:(Required)

Date(Required)

DD slash MM slash YYYY

Do you have wounds or breaks in your skin?(Required)

Yes

Details:(Required)

Please cover with dressing, if possible.

Have you had a fall in the last 12 months?(Required)

Yes

Specify(Required)

Slipped

Tripped

Lost balance

When?(Required)

Did you sustain an injury?(Required)

Limb paralysis or weakness(Required)

Yes

Specify(Required)

Right

Left

Any limitations in movement?(Required)

Do you use a walking aid?(Required)

Yes

*If YES, MUST BRING ON ADMISSION DAY

Tick if applicable:(Required)

Stick

Frame

Other

Do you need help with moving, dressing or undressing?(Required)

Yes

Specify(Required)

moving

dressing

undressing

Details:(Required)

Do you have anaphylaxis?(Required)

Yes

Details:(Required)

PLEASE BRING YOUR ADRENALINE AUTOINJECTOR, IF ANY

Do you have any known allergy or adverse reaction?(Required)

Yes

Details:(Required)

Reactions:(Required)

Do you have a dietary restriction or food intolerance?(Required)

Yes

Details:(Required)

Reactions:(Required)

Any current medication?

Yes

CURRENT MEDICATIONS

Please list all medications below. Include blood thinners, steroids, diabetic medications, over the counter medications, inhalers, topical, eye drops, pain relievers, herbal medication.

CURRENT MEDICATIONS

MEDICATION

DOSE

PLEASE TICK BOX IF THIS APPLIES

If you are diabetic or on blood thinners:

I have discussed a diabetes / blood thinners management plan with a doctor/nurse.

Surgical History

Please list any previous operations or procedure and dates.

Provide Details:

PATIENT’S DECLARATION

Declaration:(Required)

I hereby declare that the above information is true and correct to the best of my knowledge.

Name(Required)

First Last

Signature(Required)