Sydney Neurosurgeon

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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
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Surename (*)
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First Name (*)
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Email Address (*)
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Date of Birth (*)
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Marital Status
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Number of Children
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Occupation
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Address
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Contact Number

Home
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Mobile
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Work
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Next of Kin
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Phone Number
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Medicare Number (*)
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Medicare Reference Number (*)
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Health Fund Details

Name
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Membership Number
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Is this approved by your insurer?
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Insurer
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Claim Number
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Case Manager's Name
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Case Manager's Contact Number
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Family doctor/GP details/Referring Doctor

Name
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Provider Number
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Address
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Phone Number
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Fax Number
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Past history of hospitalisation or surgery

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