Patient Details:
Patient seeing the doctor
Title
*
Dr
Mr
Mrs
Ms
Miss
Master
Patients Full Name
*
First Name
Middle Name
Last Name
Preferred Name
If applicable
Date of Birth
*
-
Day
-
Month
Year
1
Gender
*
Male
Female
Transgender
Ethnicity
*
Australian, Italian, French etc.
Medicare Number
*
(10 Digits)
Medicare Reference
*
1
2
3
4
5
6
7
8
9
0
Number beside name
Medicare Expiry
*
MM / YYYY
Do you hold any of the following HCC/DVA/PCC
*
HCC - Heath Care Card
DVA - Veteran Heath Card
PCC - Pension Concession Card
None of the above
Other
Card Number
Expiry Date
-
Month
-
Day
Year
2
Do you identify as Aboriginal or Torres Straight Island?
*
Neither
Aboriginal
Torres Straight Island
Both
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Phone Number
*
Alternative Phone Number
E-mail
example@example.com
Do you wish to receive SMS appointment reminders
*
Yes
No, I don’t need a text
Marital Status
*
Single
Married
Defacto / In a relationship
Seperated
Divorced
Widowed
Country of Birth
*
Occupation
*
Next of kin
*
First Name
Last Name
Relationship to you
*
Contact Phone Number
*
Alternative Phone Number
Is emergency contact the same as next of kin?
*
Yes
No- I want to add another contact
Emergency Contact
First Name
Last Name
Relationship to you
Contact Phone Number
Alternative Phone Number
Back
Next
HEALTH SUMMARY
Height
*
cm
Weight
*
kg
Are childhood immunisations up to date
*
Yes
No
Unsure
Tetanus
(Year)
Flu
(Year)
Pneumococcal
(Year)
Do you have any allergies
*
Yes
No
Unsure
Specify type of reaction
eg: rash
History of Medical Problems
Include year of onset or diagnosis
History of operations
including year
Family History
Current Medications
Smoking Status
*
Never
Current
Ex
Year Started
-
Day
-
Month
Year
Date
Year Stopped
-
Day
-
Month
Year
Date
Do you drink alcohol
*
Yes
Never
How many days a week
1-2
3-4
5+
On days drinking, number of standard drinks consumed?
Last Pap Smear
Date - estimate
Last Mammogram
Date - estimate
Signature
*
3
Submit
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