Patient Information Form

    First Name *
    Surname *
    Date of birth *
    Email *
    Street Address *
    Suburb and Post Code *
    Phone Number *

    Medicare Number & Ref

    #
    (Please tick which)
    Expiry:
    Pos on Card:
    #
    Expiry:
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    Pension Number
    #
    Expiry:
    Pos on Card:
    Health Care Card Number
    #
    Expiry:
    Pos on Card:
    Private Health Cover
    #
    Expiry:
    Pos on Card:

    Next of Kin Details

    Name
    Emergency Contact No.
    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?
    If we need to contact you what is your preferred method of contact:
    Home PhoneEmailMobile
    Are 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?
    To assist with health initiatives – are you an Aboriginal or Torres Strait Islander?
    NoYes – AboriginalYes - Torres Strait IslanderYes – Aboriginal & Torres Strait Islander
    Are there any health concerns that you would like to receive information on?
    Your Health History
    Do you have or have you had a history of the following?
    Please elaborate
    Do you have any allergies or are you sensitive to drugs or dressings?
    Please elaborate
    Immunisations

    Have you had the following immunisations? (list date where appropriate)

    Tetanus Booster
    Hepatitis B
    Hepatitis A
    Influenza
    Pneumococcal
    Polio
    If completing this form for a child are their immunisations up to date?
    Current Medications

    Please list all current medications including over the counter medicationsvitamins and minerals:

    Family History
    Have any members of your family had:

    Other (please elaborate)
    Social History

    Do you use any of the following: (list amount where appropriate)

    Tobacco
    Number Day / Week

    Alcohol
    Number Day / Week / Month

    Drug Use
    Type /Frequency

    Measurements:
    Height (cm)
    Weight (kg)


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