New Patient Registration Title—Please choose an option—MrMrsDrMsMissMaster Surname First Name Address Postal Code Date of Birth Country Birth Contact Phone No Home Work Mobile Occupation Email-id Medicare Number Ref Expiry Date Pension Card No Expiry Date Health care Card No: Expiry Date Veterans Affairs No: Expiry Date Emergency Contact Name: Relationship : Contact Number: Any information you can provide will assist our doctors to provide optimum care for you and our family.If you prefer to provide this information directly to the doctor, please advise the reception staff.All staff is bound by confidentiality agreements to maintain your privacy. Are You:—Please choose an option—AboriginalTorres Strait IslanderBothNeither Past History Have you ever been in a hospital?—Please choose an option—YesNo If yes for what reason and when? Allergies: Are you allergic or sensitive to any medications? Provide details below Do you suffer from any of these medical conditions?AsthmaDiabetesHypertensionHeart DiseaseMental Illness Do you take any regular medications?—Please choose an option—YesNo If yes please list: Female: When did you last have? Pap Smear: Breast Check up Social History Do you smoke?—Please choose an option—YesNo If Yes how many per day or week? Have you smoked previously?—Please choose an option—YesNo If yes when did you give up smoking? Do you smoke Marijuana?—Please choose an option—YesNo If yes how often? Do you drink alcohol?—Please choose an option—YesNo If yes how often? Any other relevant history Family History Have any of your family members have or had? AsthmaDiabetesHypertensionHeart DiseaseMental IllnessCancerOther Your Height and Weight Height: Weight: Blood Pressure: Body mass index Please let us know if you are here for Complete Health AssessmentEPC Care PlanAsthma ReviewPap Smear reviewMedication ReviewOther Privacy Agreement & Patient consent: Your medical record is a confidential document. It is the policy of this practice to maintain security of personal health information at all times to ensure that this information is only available to authorized members of staff. We abide by the National Privacy Principles available at www.privacy.gov.au/health/index.html. Our practice provides our patients with preventative care and early case detection reminders e.g.: immunisations, annual health checks, skin checks and pap smears and you agree to be part of a recall system. Input this code:
