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. The purpose of this questionnaire is to help your doctor to assess your health This information is treated confidentially. Doctor seen on initial consultation: Date: Male /Female (Circle one) Dr Mr Mrs Ms Miss Title Surname First Name Occupation Date of Birth Street Address Suburb and Post Code Mobile Phone : Home Phone: Work Phone: Medicare Number & Ref #: Next of Kin NOK Contact no: Name: Exp: / Relationship: Pension Number #: Exp: DVA Gold DVA White #: (Please tick one) Exp: / / HCC Number #: Private Health #: Exp: / 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? No Yes. Please elaborate: To assist with health initiatives are you an Aboriginal or Torres Strait Islander? – No Yes Aboriginal Yes Torres Strait Islander Yes - Aboriginal & Torres Strait Islander – – Your Health History - Do you have or have you had a history of the following? (please elaborate) Operations/procedures: Asthma Diabetes Hypertension Heart disease Breast Cancer Bowel Cancer Chronic Illness: Other: Hospital admissions in last 12 months? No Yes: FAMILY HISTORY of any of the above? (Please list condition and relationship): Do you have any ALLERGIES or are you sensitive to drugs or dressings? No Yes. Please elaborate:
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. The purpose of this questionnaire is to help your doctor to assess your health This information is treated confidentially. Doctor seen on initial consultation: Date: Male /Female (Circle one) Title Dr Mr Mrs Ms Miss Surname First Name Occupation Date of Birth Street Address Suburb and Post Code Mobile Phone : Home Phone: Work Phone: Medicare Number & Ref #: Exp: / Next of Kin Name: Relationship: NOK Contact no: Pension Number #: Exp: / DVA Gold DVA White (Please tick one) #: Exp: / HCC Number #: Exp: / Private Health #: 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? No Yes. Please elaborate: To assist with health initiatives – are you an Aboriginal or Torres Strait Islander? No Yes – Aboriginal Yes – Torres Strait Islander Yes - Aboriginal & Torres Strait Islander Your Health History - Do you have or have you had a history of the following? (please elaborate) Operations/procedures: Asthma Diabetes Hypertension Heart disease Breast Cancer Bowel Cancer Chronic Illness: Other: Hospital admissions in last 12 months? No Yes: FAMILY HISTORY of any of the above? (Please list condition and relationship): Do you have any ALLERGIES or are you sensitive to drugs or dressings? No Yes. Please elaborate:
patient_registration_form_with_privacy_and_consent.docx