PRIVACY POLICY

The Privacy Act requires us to inform you about the information we will collect about you and what we will do with this information.

What information will we collect:

Your personal details.
Details of the condition we are treating.
Your medical history.
A photo of you on arrival.

What we will do with the information:

1. Provide you with quality health care

The information will be used to properly assess, diagnose and treat you.

2. Communication with others involved in your care

A letter outlining the outcome of your consultation will be sent to your referring doctor, and other therapists involved in your care, as well as any doctor or therapist you are referred to throughout your treatment. Our group of practices includes doctors, nurses and allied health professionals at SpinePlus, BackSpace and Axxon Pain Medicine and these health professionals will have access to your medical records if they are involved in your care.

3. Administrative purposes

This includes maintenance of records and billing, being contacted for any purpose relating to your medical care, and the possibility of information being forwarded to a collection agency in the event of an outstanding account.

3. Research and education

Your doctor is involved in teaching, research and quality assurance. They may take photographs of your x-rays and scans, and use them for teaching purposes. Your name will NOT be disclosed.

Your care will involve the collection of information about your treatment including your progress, frequency and nature of your treatment. Information collected may be used for research. All information collected and utilised will be deidentified.

We respect your privacy and will not disclose your information in any other way without your permission.

4. Students

Medical, nursing or allied health students may be present during your consultation, but will be observing only and not be involved in your care. PLEASE NOTIFY US if you do not want a student present.

I have read the above information and understand what information is collected, why it is collected and how it is used and shared.

I DO agree to the above termsI DO NOT agree to the above terms

PATIENT DETAILS

Gender *

MaleFemale

First Name *

Last Name *

Preferred Name

Date Of Birth *

Home Phone

Mobile Phone *

Email *

Address *

COVID-19 Vaccination Status: *

Fully vaccinatedAt least 1 doseUnvaccinatedExempted from vaccination

NEXT OF KIN CONTACT DETAILS

Name *

Mobile Phone *

REFERRAL

Do you have a referral?

YesNo

Referring Doctor’s Name

Clinc

MEDICARE

Medicare Card No.

Reference No.

Expiry

PRIVATE HEALTH INSURANCE

Do you have private health insurance? *

Yes No

Provider

Membership No.

DVA

Do you have a DVA card? *

YesNo

DVA No.

Condition

Expiry

WORKCOVER

Do you have an active WorkCover claim? *

YesNo

Claim No.

Case Manager Name

Case Manager Phone

Case Manager Email

LEGAL

Do you have an active legal claim? *

YesNo

Is this a CTP claim for a car accident?

YesNo

Is there a lawyer involved in your care?

YesNo

PREVIOUS TREATMENT

Are you a previous patient of Dr Paul Licina?

YesNo

Have you seen another specialist for your current condition?

YesNo

Details:

Have you had any treatment for this condition?

YesNo

Details:

If surgery was recommended is this something you would consider?

YesNoUnsure

SYMPTOMS

Where are your symptoms? (select all that apply)

NeckArmBackLeg

Which side are your symptoms? (select all that apply)

LeftRight

NECK

Is your pain the result of a car accident, fall or crush injury?

YesNo

Was an ambulance called?

YesNo

Did you present to the emergency room within 48 hours of your accident?

YesNo

Do you have confirmed spine fractures on imaging?

YesNo

BACK

Is your pain the result of a car accident, fall or crush injury?

YesNo

Was an ambulance called?

YesNo

Did you present to the emergency room within 48 hours of your accident?

YesNo

Do you have confirmed spine fractures on imaging?

YesNo

ARM

Do you have severe weakness in your arms AND legs?

YesNo

Do you have difficulty using your arms and hands?

YesNo

Do you have pins and needles or numbness in your arms and legs?

YesNo

Do you have difficulty walking any distance?

YesNo

Do you have severe weakness in your arms or hands?

YesNo

Do you have difficulty pushing, pulling or lifting objects?

YesNo

Do you have difficulty gripping objects?

YesNo

Have you noticed any muscle wasting?

YesNo

Do you have severe arm pain?

YesNo

Is your arm pain more severe than your neck pain?

YesNo

Do you have pain that radiates down the arm to the hand or fingers?

YesNo

Do you have numbness, pins and needles or tingling in the shoulder, arm or hand?

YesNo

LEG

Do you have severe pain or weakness in BOTH legs?

YesNo

Do you have trouble standing or walking more than a few steps unaided because of weakness?

YesNo

Do you have severe numbness or pins and needles in your groin or down both legs?

YesNo

Have you developed inability to urinate or loss of control of your bladder?

YesNo

Have you noticed any weakness in ONE foot?

YesNo

Have you noticed that your foot drags, flops or catches when you walk?

YesNo

Do you have difficulty standing on your heels or toes due to weakness?

YesNo

Do you have pins and needles, tingling or numbness in your foot?

YesNo

Do you have severe pain in ONE leg?

YesNo

Is your leg pain more severe than your back pain?

YesNo

Does the pain run down the back or side of your leg?

YesNo

Does the pain go past your knee?

YesNo

Do you get pain or heaviness in your legs when you walk?

YesNo

Does the pain or heaviness come on the further you walk?

YesNo

Do you get relief from sitting?

YesNo

Do you find yourself stooping or leaning forward (i.e. on a shopping trolley) when walking?

YesNo

SEVERITY

MEDICATION

Are you taking any pain medication?

YesNo

DURATION

How long have you had your current symptoms?

less than 6 weeks6 weeks to 6 months6 month to 2 yearsmore than 2 years

ADDITIONAL INFORMATION

Is there any additional information you would like us to know?

IMAGING

Have you had any previous scans related to your condition?

MRICTXrayNo

Please specify:

In case we need to order further imaging. Do any of the following safety questions apply?

Have you had previous spine surgery?

YesNo

Details:

Do you have any metal implants?

YesNo

Details:

Are you claustrophobic?

YesNo

Would you prefer intravenous or oral sedation?

IntravenousOralUnsure

Please confirm you are not a robot *