Adelaide Shoulder & Upper Limb Clinic
Patient Registration Form
Welcome
Before we begin
Please read the following, then tick to confirm you agree before continuing. This should take about 8–10 minutes.
I have read and agree to the above. I understand my care is to be undertaken by Adelaide Shoulder & Upper Limb Clinic as an independent specialist.
Step 1 of 13
Which area are you being seen for?
This determines which functional questionnaire you'll complete at the end.
💪
Shoulder
🦾
Elbow
🤝
Wrist
✋
Hand / Finger
Step 2 of 13
Your personal details
Step 3 of 13
Medicare & health insurance
e.g. 12/2027
Yes
No
Yes
No
Step 4 of 13
Your doctors & referral
Yes
No
Step 5 of 13
How did you find us?
ASULC website
GP referral
Specialist referral
Physio referral
Trauma (A&E)
Personal recommendation
Google / Health Engine
Newspaper
Repeat patient
Self referral
Expertise on website
Online reviews
Personal recommendation
Convenient location
Affordable fees
Physio / Allied Health
GP referral
Specialist referral
Step 6 of 13
Work injury or insurance claim?
Yes
No
Yes
No
Step 7 of 13
About you
This information helps us assess your problem.
Right-handed
Left-handed
Step 8 of 13
Your symptoms
Right
Left
Both
Pain
Instability
Weakness
Stiffness
Numbness / Tingling
0
1
2
3
4
5
6
7
8
9
10
No painWorst possible
Constant
Comes & goes
Step 9 of 13
Injury details & treatment
Yes
No
Anti-inflammatories
Prescription pain medication
Physical therapy / physio
Injections
Surgery
None tried
Step 10 of 13
Medical history
Arthritis
Asthma
Diabetes
Bleeding disorder
Clotting disorder
High blood pressure
Breathing problems
Chest pain / angina
Cancer
Hepatitis
Heart attack
Heart condition
Kidney disease
Lung disease
Seizures
Stomach ulcers
Stroke / TIAs
Thyroid disease
None of the above
Yes
No
Not sure
e.g. leukaemia, HIV, radiotherapy, chemotherapy, steroid therapy
Yes
No
Not sure
Step 11 of 13
Medications & health
Yes
No
Previously
Yes
No
Not sure
Apixaban (Eliquis)
Aspirin
Clopidogrel (Plavix)
Dabigatran (Pradaxa)
Dipyridamole (Persantine)
Edoxaban (Savaysa)
Fish oil
Fondaparinux (Arixtra)
Heparin
Prasugrel (Effient)
Rivaroxaban (Xarelto)
Ticagrelor (Brilinta)
Vorapaxar (Zontivity)
Warfarin (Coumadin)
None
Step 12 of 13
Imaging studies
Please tell us where you have had any scans or X-rays performed.
Benson Radiology
Dr Jones & Partners
Fowler Simmons
Goodwood Diagnostic
Perrett's
Radiology SA
Sound Radiology
RAH / QEH / Repat
Other public hospital
Unsure
No imaging done
X-ray
Ultrasound
MRI
CT scan
Bone scan
Yes
No
N/A
Almost done!
Review & submit
Please check your details below, then tap Submit to send your registration to the clinic.
By submitting, your registration and clinical summary will be emailed securely to the Adelaide Shoulder & Upper Limb Clinic.