Patient Intake Form — Dr Yasser Farooque Practice

1. Your Details & Emergency Contact

Step 1 of 7

Title Mr Ms Mrs Master Miss Other

Full Name Date of Birth

Gender Are you pregnant?

Yes No

Mobile Number

Email Address Residential Address

Residential Status Aboriginal or Torres Strait Islander status

Emergency Contact Contact Phone Relationship

2. Medicare & Insurance

Step 2 of 7

Do you have Medicare?

Yes No

Medicare Card Number (10 digits) IRN (number next to your name) Expiry (MM/YYYY)

As a Medicare-ineligible patient, I acknowledge that payments may be out-of-pocket expenses, and a credit card number is required for security if procedure or surgery is required.

Do you have a Department of Veterans' Affairs (DVA) card?

Yes No

Card Number Expiry (MM/YY)

Card Type

Gold White Orange

Do you have Private Health Insurance?

Yes No

Health Fund Name Health Fund Number

Is this consultation related to a Third Party Claim?

Yes No

Claim Type

Workers Comp CTP (Trauma/MVA)

Insurer Claim Number Injury Date

Brief Injury Description

Do you have a Concession Card? (e.g. NSW Aged Pensioner Concession)

Yes No

Concession Number Expiry (MM/YY)

Note: YF Surgery provides a rebate ONLY to valid NSW Aged Pensioners.

3. GP & Referral

Step 3 of 7

Referring Doctor Practice / Clinic Name

Practice Contact Number

Reason for consultation (in your own words)

Usual GP Details (if different than referrer)

Usual GP Name GP Practice Name GP Practice Contact Number

Other Specialists (tick all that apply and provide details)

Cardiologist Gastroenterologist Liver Specialist Renal (Kidney) Specialist Neurologist Respiratory physician Endocrinologist (diabetes Specialist) Other surgeon / Bariatric (weightloss) Surgeon

Please bring your referral to the practice or e-mail it to Reception@YFSurgery.com.au

4. Work & Social Support

Step 4 of 7

Currently employed?

Yes No

Occupation

Living arrangement (Social Support) Will you require social / discharge support if surgical treatment is offered?

Yes No

5. Medical & Surgical History

Step 5 of 7

Height (cm) Weight (kg)

BMI

Enter height & weight

Lifestyle

Smoking Alcohol use Physical Activity

Medical conditions

Any medical conditions? None Yes

Cardiovascular

Hypertension Low Blood Pressure Angina Previous Heart Attack Previous Bypass Surgery Heart Valve Disease Previous Heart Valve Surgery Chronic Vascular Diseases DVT Heart Failure

Respiratory

Asthma / COPD Emphysema Tuberculosis Previous Lung Surgery

Diabetes & Endocrine

Diabetes (Type 1 / Type 2) Thyroid Disorder (Hypo / Hyper)

Renal

Renal Failure

On Haemodialysis On Peritoneal Dialysis

Neurological

Stroke Seizures

Hepatic & Gastrointestinal

Liver Disease Hep B / Hep C Gallbladder / Biliary conditions Pancreatic Conditions Reflux Ulcers Inflammatory Bowel Disease Previous Gastrointestinal or Bariatric Surgery

Oncology

Cancer

Additional / General

Anaemia Psychiatric Problems Depression Anxiety HIV+ / AIDS Other Auto Immune conditions

Other (free text)

Medications

Are you currently taking medications? None Yes

Common medications

Aspirin Warfarin Clopidogrel (Plavix) Steroids Chemotherapy Immunosuppressant

Diabetic medications

Tablet medications

Injections

Insulin Ozempic Wegovy Saxenda Mounjaro Trulicity

Other medications & supplements

Herbal Homeopathic Chinese meds Fish oils Supplements

Other medications (free text)

Previous operations / procedures?

Yes No

6. Cultural & Religious Considerations

Step 6 of 7

These questions help us understand any spiritual or cultural preferences relevant to your care.

Religion / Faith (optional) Do you have any religious or cultural requirements related to dietary restrictions?

No Yes — Please specify:

Halal Kosher Vegetarian Vegan Fasting Requirements

Other dietary restrictions

Do you have any religious or cultural requirements related to medications or ingredients you wish to avoid?

No Yes — Please specify:

Gelatin-based capsules Alcohol-containing solutions Pork (porcine) derived products Beef (bovine) derived products

Other medication restrictions

Blood products or transfusions

No Concerns No Blood Products Please Prefer Alternatives — Please Specify:

Blood product preference details

7. Consent, Signature & Submit

Step 7 of 7

Our practice may coordinate care with other providers. We seek your informed consent to share relevant information strictly where appropriate and lawful (e.g., where required by law, impracticable to obtain consent, or to prevent or lessen a serious risk to life, health or safety).

I am aware I can access my personal information. I am aware I can withdraw consent at any time. I understand my provider must comply with privacy laws and I can contact the organisation if I believe these have been breached. I understand why limited information may be shared to coordinate my care.

Full name (signature) Date

I confirm the above signature and typed name are my consent and acknowledgment.

1. Your Details & Emergency Contact

2. Medicare & Insurance

3. GP & Referral

4. Work & Social Support

5. Medical & Surgical History

6. Cultural & Religious Considerations

7. Consent, Signature & Submit

Preparing your e-mail…