We are committed to providing our patients with the best care. To do this it is essential that your health record is kept up to date and accurate. Could you please assist us by completing the following:Surname *First Name *Date of birth *Street Address *Suburb and Post Code *Mobile Phone *Email * Medicare Number & Ref# Expiry: Pos on Card: (Please tick which) *DVA GoldDVA White# Expiry: Pos on Card: Pension Number# Expiry: Pos on Card: Health Care Card Number# Expiry: Pos on Card: Private Health CoverName: # Name and Telephone number Name and Telephone number of the person we can contact if needed Employer Name Employer Address Employer telephone no. Reminder Systems: Our practice provides our patients with preventive care and early case detection reminders e.g. immunisations, annual health checks, skin checks and pap smears.Do you wish to have any relevant health reminders sent to you? Yes – by MailNoIf we need to contact you what is your preferred method of contact: Home PhoneEmailMobileAre there any health concerns that you would like to receive information on? Patient Background: Australia is a genuinely multicultural society. To tailor appropriate care, encourage understanding and appreciation between people from different nationalities and backgrounds.Do you identify as someone from a culturally and/or linguistic diverse background? NoYesTo assist with health initiatives – are you an Aboriginal or Torres Strait Islander? NoYes – AboriginalYes - Torres Strait IslanderYes – Aboriginal & Torres Strait Islander Your Health HistoryDo you have or have you had a history of the following? OperationsAsthmaDiabetesHypertensionChronic IllnessOtherPlease elaborate Do you have any allergies or are you sensitive to drugs or dressings? NoYesPlease elaborate: ImmunisationsHave you had the following immunisations? (list date where appropriate) Tetanus Booster Don’t KnowNoYes. Date: Hepatitis B Don’t KnowNoYes. Date: Hepatitis A Don’t KnowNoYes. Date: Influenza Don’t KnowNoYes. Date: Pneumococcal Don’t KnowNoYes. Date: Polio Don’t KnowNoYes. Date: Children’s ImmunisationsIf completing this form for a child are their immunisations up to date? YesNoCurrent Medications Please list all current medications including over the counter medications, vitamins and minerals: Family HistoryHave any members of your family had: Heart DiseaseAsthmaDiabetesMental IllnessCancerOther (please elaborate) Social HistoryDo you use any of the following: (list amount where appropriate)Tobacco Ceased smokingNoYes Alcohol NoYes Drug Use NoYes Measurements: Sun Protection How often do you use the following to protect yourself from the sun when outdoors? Blood Pressure: When was the last time your blood pressure was taken? Protective clothing AlwaysOftenSometimesRarelyNeverSunscreen creams AlwaysOftenSometimesRarelyNeverFor those 65 years and older: When was the last time you were immunised?Influenza Not sureNever Pneumococcal pneumonia Not sureNever Females When did you last have?Pap Smear Not sureNever Breast Check Not sureNever Males When did you last have?Overall Checkup Not sureNever VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
(03) 93001244
+61422091153 
5 Blucher St, Glenroy VIC 3046
