First Name *Surname *Date of birth *Email *Street Address *Suburb and Post Code *Phone Number *Medicare Number & Ref#(Please tick which) *DVA GoldDVA WhiteExpiry:Pos on Card:#Expiry:Pos on Card:Pension Number#Expiry:Pos on Card:Health Care Card Number#Expiry:Pos on Card:Private Health Cover#Expiry:Pos on Card:Name and Telephone numberName and Telephone number of the person we can contact if neededEmployer NameEmployer AddressEmployer 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?YesNoTo assist with health initiatives – are you an Aboriginal or Torres Strait Islander?NoYes – AboriginalYes - Torres Strait IslanderYes – Aboriginal & Torres Strait IslanderAre there any health concerns that you would like to receive information on?Your Health HistoryDo you have or have you had a history of the following?OperationsAsthmaDiabetesHypertensionChronic IllnessOtherPlease elaborateDo you have any allergies or are you sensitive to drugs or dressings?YesNoPlease elaborateImmunisationsHave you had the following immunisations? (list date where appropriate)Tetanus BoosterDon’t KnowNoYes. Date:Hepatitis BDon’t KnowNoYes. Date:Hepatitis ADon’t KnowNoYes. Date:InfluenzaDon’t KnowNoYes. Date:PneumococcalDon’t KnowNoYes. Date:PolioDon’t KnowNoYes. Date:If completing this form for a child are their immunisations up to date?YesNoCurrent MedicationsPlease list all current medications including over the counter medicationsvitamins 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)TobaccoCeased smokingNoYesNumber Day / WeekAlcoholNoYesNumber Day / Week / MonthDrug UseNoYesType /Frequency Measurements: