Health Questionnaire

Which location are you booked in to see Dr Vivek Arora?

Other hospital (Please specify)

Patient Registration

Some description about this section

First Name

Middle Name

Last Name

Preferred Name

Date Of Birth

Home Address

Address Line 1

Address Line 2

City

State

Postcode

eg. 2000

Postal Address

My Postal Address is Different

Postal Address (if different)

Address Line 1

Address Line 2

City

State

Postcode

Occupation

Language(s) Spoken

Contact Details

Home Phone

Mobile Phone

Work Phone

SMS and Email Correspondence

We send you a text message (SMS) 2 days before your scheduled appointment as a reminder.

As a paperless practice, we use email as the preferred mode of communication to send you copies of clinic letters and other treatment related documents. Your email address will not be published.

Please speak to the practice staff if you do not wish to receive email communications or SMS appointment reminders.

Emergency Contact

First Name

Last Name

Phone/Mobile

Medicare/Health Fund Details

Medicare Number

The 10 digit number on the front of your card.

Ref No.

The number next to your name

Expiry Date (as written on card)

eg. 10/2022

Health Fund Name

Membership No.

Your General Practitioner

GP Name

GP Phone

GP Address

GP Fax

Your Referring Doctor

Referring Doctor Name

Referring Doctor Phone

Referring Doctor Address

Referring Doctor Fax

Correspondence will automatically be sent to your referring doctor and copied to your GP. Please inform us if you do not want correspondence sent.

How did you hear about us?

Practice Information

Privacy Notice

The personal and health information that is provided by you and recorded in your Electronic Health Record will be collected for the purpose of providing you with treatment. Your information is collected and held in accordance with NSW privacy legislation under which you have rights of access and correction. For more information please read our practice privacy policy.

Consent to Release of Medical Information

I give my consent to Yanada Women’s Health Pty Ltd, or their agent and advisors, to contact medical practitioners or other bodies who I have consulted to obtain health and other information that may be pertinent to my care. I authorize those medical practitioners or bodies to release such information, which may include sensitive health information, to Yanada Women’s Health Pty Ltd, or their agent and advisors, as may be requested. I understand that unless I advise otherwise, Yanada Women’s Health Pty Ltd will continue to liaise with the doctors nominated by me on matters related to my ongoing care.

Cancellation Policy

Yanada Women’s Health Pty Ltd does not charge any cancellation fees, but we do ask that you inform us if you intend to miss your appointment, so that we can offer it to someone who may need it more urgently.

For more information please read the practice Terms and Conditions.

Research Consent

Your information may be used by Yanada Women’s Health Pty Ltd/or Prince of Wales Private Hospital, to contact you for research or to evaluate by the way of audit, the service and/or medical treatment that you have received. Any information that you provide for the audit or research purposes will not identify you in any way.

Consent for Research

I DO CONSENT to be contacted at a future date for research/ audit purpose

I DO NOT CONSENT to be contacted at a future date for research/ audit purpose

Your Acknowledgment

I have read and understood the above information and policies, terms & conditions and privacy policy regarding Yanada Women’s Health Pty Ltd. I reserve the right to change my consent at any point on written request. I understand that my acknowledgement of above will be recorded in my Electronic Health Record.

I have read and understood the above Privacy Policy and release of medical information

Thank you for taking the time to read this information.

	Yes	No
Have you ever been sexually active
Are you in a current relationship

	Yes	No
Do you experience pain during intercourse (if applicable)
Have you experienced bleeding after intercourse (if applicable)

	Yes	No
Do you consider your periods to be heavy (if applicable)
Are your periods painful (if applicable)
Do you need to take time off from work/study due to your period related symptoms (if applicable)

	Yes	No
Have you ever been pregnant
Have you ever received fertility treatment

Patient Registration

Contact Details

SMS and Email Correspondence

Emergency Contact

Medicare/Health Fund Details

Your General Practitioner

Your Referring Doctor

Practice Information

Research Consent

Your Acknowledgment

Health Questionnaire

Have a question?

Dr Vivek Arora

I’m a Sydney-based gynaecologist and gynaecological oncologist who provides prompt and compassionate care in a warm, supportive environment that empowers women to make informed decisions.

Locations

Expertise

About

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