First Visit

To organize your information, you can print and complete a General Questionnaire form. Also you can fill out the following form and submit it before your appointment with Dr. Kohan. Upon completion, you will recieve an email with 3 other forms attached (Form 1, Form 2, and Form 3), which you will need to fill them out and bring them with you.

Personal Details
Title	Invalid Input
Surename (*)	Invalid Input
First Name (*)	Invalid Input
Email Address (*)	Invalid Input
Date of Birth (*)	Invalid Input
Marital Status	Invalid Input
Number of Children	Please enter number only
Occupation	Invalid Input
Address	Invalid Input
Contact Number
Home	Invalid Input
Mobile	Invalid Input
Work	Invalid Input

Next of Kin	Invalid Input
Phone Number	Invalid Input

Medicare Number (*)	Invalid Input
Medicare Reference Number (*)	Invalid Input
	Invalid Input

Health Fund Details
Name	Invalid Input
Membership Number	Invalid Input

Is your problem related to work injury?	NoYes Invalid Input
Is this approved by your insurer?	YesNo Invalid Input
Insurer	Invalid Input
Claim Number	Invalid Input
Case Manager's Name	Invalid Input
Case Manager's Contact Number	Invalid Input

Family doctor/GP details/Referring Doctor
Name	Invalid Input
Provider Number	Invalid Input
Address	Invalid Input
Phone Number	Invalid Input
Fax Number	Invalid Input

Past history of hospitalisation or surgery
Please list your complaints / hospital / and year	Invalid Input
Any Problems with Anaesthetics?	YesNo Invalid Input
	Other Health Issues
Diabetes	YesNo Invalid Input
Kidney Problem	YesNo Invalid Input
Stomach Ulcer	YesNo Invalid Input
Heart Problems	YesNo Invalid Input
Breathing Problems	YesNo Invalid Input
High Blood Pressure	YesNo Invalid Input
Cancers	YesNo Invalid Input
Please list your current medication, includes the dosage	Invalid Input
Are you on Aspirin or Warfarin or any other blood thinning medication	YesNo Invalid Input
Please list any allergies, if any	Invalid Input
Are you or have you been a smoker?	YesNo Invalid Input
How Long	Invalid Input
Cigarettes per Day	Invalid Input
Do you drink alcoholic drinks	YesNo Invalid Input
Average Daily Consumption	Invalid Input

Sydney Neurosurgeon

First Visit

Personal Details

Contact Number

Health Fund Details

Family doctor/GP details/Referring Doctor

Past history of hospitalisation or surgery

Forms

For Surgery

First Visit

Download the Forms