Step 1 of 425%INFORMATIONAddress Suite 501, Level 5, Pindara Specialist Suites 29 Carrara Street Benowa Qld 4217. Parking There is available undercover parking. Requirements In order for Prostate Clinic to plan appropriately for your consultation please alert staff prior to your appointment if you: Have a letter from your referring doctorRequire mobility assistance during consultation (ie wheel chair, lifting)Are hearing or sight impairmentHave a contagious /infection conditionRequire other specialised assistance during your consultation. Please bring with you to the consultation:Questionnaire completedCurrent Medicare card / Veteran’s Affairs CardHealth Fund Card / details.Any x-rays, scans or test results relating to your problemPlease note a urine test will be required at time of consult. Please drink at least 1 Litre of water 60 minutes prior to consultation. Failure to provide a flow test may delay your appointment.PLEASE COME WITH A FULL BLADDER. DO NOT GO TO THE TOILET DOWNSTAIRS Cost The cost of the consultation is between $150 & $240, payable on the day and claimable from Medicare. We charge the AMA rate fees and do not participate in the "NO GAP SCHEME". All procedures will be billed to the patient for your submission to your health fund. You may obtain a quote prior to your operation for all out of pocket expenses.FORMNew referral(Required) Yes NoName(Required) First Last Date of Birth(Required) DD slash MM slash YYYY Referring Doctor(Required)How did you hear about Dr Chabert?(Required) Website Word of mouth GP Referral OtherOther(Required)Your GP(Required)Postal Address PO Box AddressEmail(Required) Enter Email Confirm Email Phone(Required)Medicare Number(Required)Expiry Date(Required)Ref No.(Required)Health FundMembership & Ref No.AllergiesHeightWeightBMIMediciations Please tick the box below if you are on any of the following blood thinnersPlease select Medications Aspirin Disprin Cartia Celebrex Anisindione Warfarin Coumadin Pradaxa Anginine Tabs Arixtra Heparin Clexane Plavix / Clopidogrel Eliquis Xarelto GTN Nitrolingual Spray / Patches Pradaxa Prednisone Thyroxine Ibuprofen / Nurofen Vitamin E Green Tea Fish Oil Herbal Vitamins Antacids or medication for Gastric RefluxMedical condition Please tick the box below if you have any of the following medical conditionsPlease select Medical conditions Diabetes Cardiac Condition Cancer Blood Disorders Epilepsy Digestive Disorder Asthma Depression Dementia High Blood Pressure Hepatitis Hernia Another medical condition not listedDetailsList conditionPermission I give permission for my results or medical condition to be discussed with my partner / spouse.Spouse / Partner nameContact NumberASSESSING PROSTATE SYMPTOMS By filling in this form, you will help your doctor to assess if you have an enlarged prostate, and how badly it is affecting you. An enlarged prostate is a common and benign (non-cancerous) condition that often occurs in older men. (The results do not help to diagnose prostate cancer.) The International Prostate Symptom Score (IPSS) Over the past month, how often have you...Had a sensation of not emptying your bladder completely after you finished urinating?(Required) Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost alwaysHad to urinate again less than two hours after you finished urinating?(Required) Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost alwaysStopped and started again several times when you urinated?(Required) Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost alwaysFound it difficult to postpone urination?(Required) Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost alwaysHad a weak urinary stream?(Required) Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost alwaysHad to push or strain to begin urination?(Required) Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost alwaysOver the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?(Required) None Once Twice 3 times 4 times 5 or more timesIf you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that? (Please tick which best describes how you would feel.)(Required) Delighted Pleased Mostly satisfied Mixed - equally satisfied and dissatisfied Mostly dissatisfied Unhappy TerriblePrivacy Consent(Required) By ticking this I agree to the privacy policy.The provision of quality health care requires a doctor-patient relationship of trust and confidentiality. Consistent with our commitment to quality care this practice has developed a policy to protect patient privacy in compliance with private legislation. It is necessary for us to collect personal information from patients and sometimes others associated with their health care in order to attend to their needs and for administrative purposes. In the interests of the highest quality and continuity of the patient’s health care this may also include sharing information with other health care providers who comprise a patient’s medical team from time to time. On the day of my surgery photos or videos of my procedure may be taken for administrative or teaching purposes. I understand at no time will my identity be photographed or filmed. I understand that Dr Chabert will protect my privacy in compliance with private legislation. This practice will also send a letter to all relevant health care providers detailing the treatment provided. I have read the above information and give my consent.How do you rate your confidence that you could get an keep an erection? Very low Low Moderate High Very highWhen you had erections with sexual stimulation, how often were your erections hard enough for penetration? Never or almost never A few times Sometimes Most times Almost always or alwaysDuring sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? Never or almost never A few times Sometimes Most times Almost always or alwaysDuring sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? Extremely difficult Very difficult Difficult Slightly difficult Not difficultWhen you attempted sexual intercourse, how often was it satisfactory for you? Never or almost never A few times Sometimes Most times Almost always or always
