Contact Information Title: MissMsMrsMrMastDr Other: Gender: MaleFemaleNon-binaryGender DiverseTransgenderDifferent Identity Given Names: (required) Preferred Name: (required) SURNAME: (required) MARITAL STATUS: SingleDefactoMarriedDivorcedWidowedN/A (Children) Date of Birth: (required) Residential Address: Suburb/Town: Postal Address: Suburb/Town: Telephone Home: Mobile No: Telephone Work: Email Address: (required) Medicare Medicare Card No: Medicare Card Reference No: Medicare Card Expiry Date Pension/Health Care Card No: Type of Pension/Health Card: PensionerHealth Care Card Pension/Health Care Card Expiry Date Type of DVA Card: GoldWhite DVA Card No: DVA Card Expiry Date *IF THE NEW PATIENT IS A CHILD UNDER 16 PLEASE PROVIDE: PARENTS NAME: Parents Date of Birth Parents Medicare Number Cultural Identity Occupation EMPLOYER: Country of Birth IF NOT AUSTRALIA, WHAT YEAR DID YOU ARRIVE: Ethnicity Australian non indigenousAboriginal but not Torres Strait IslanderTorres Strait Islander but not AboriginalBoth Aboriginal and Torres Strait Islander Language Spoken Other Than English Do you identify as being any of following? AboriginalTorres Strait IslanderAboriginal and Torres Strait IslanderLGBTQ+ Next of Kin/ Emergency Contact Name: Relationship to Patient: Phone No: Address: Emergency Contact Name: Relationship to Patient: Phone No: Address: Allergies and medicines DO YOU SUFFER FROM ANY OF THE FOLLOWING: Heart DiseaseThyroid DisordersArthritisRespiratory DiseaseDiabetes- Type 1 / Type 2Bowel ProblemsHigh Blood PressureAbnormal Cervical ScreeningStrokeTumours/ CancersProstate ProblemMental Illness Any other medical conditions/past surgeries: Allergies/ Adverse Reactions: Current Medications: Family and Social History FAMILY HISTORY (INCL. PARENTS, SIBLINGS, GRANDPARENTS): Heart DiseaseDiabetes- Type 1 / Type 2High Blood PressureStrokeTumours/ CancersHigh Cholesterol Smoking and Alcoholic History Smoker Never SmokedEx-SmokerSmoker If Ex-Smoker, Year Quit: If Smoker, Number/Day: Alcohol NeverMonthly or less2-4 Times per month2-4 Times per week4+ Times per week How many standard drinks would you consume each time you drink: Preventative Health / 45-49 Health Assessment Have you ever had Diabetes Risk Assessment: YesNo If yes, Date: Heart Health Check: YesNo If yes, Date: Mental Health Screening: YesNo If yes, Date: Menopause Assessment: YesNo If yes, Date: A Skin Check: YesNo If yes, Date: A Colonoscopy? YesNo If yes, Date: Are your Immunisations up to date? YesNoNot Sure Women only Have you ever had A Cervical Screening? YesNo Date: Was it: NormalAbnormal A Breast Screen? YesNo Date: Was it: NormalAbnormal Men only Have you ever had Prostate Check? YesNoDate of last check: Was it: NormalAbnormal IF YOU ARE OVER 65 YEARS OLD: Influenza Vaccine?YesNo Pneumococcal Vaccine?YesNo Bone Density Scan?YesNo Most recent hearing check?YesNo Most recent eye check?YesNo Most recent dental check?YesNo Will / Powers of Attorney?YesNo Appointed Medical Treatment Decision-Maker?YesNo Advanced Care Directive?YesNo Aged Care Assessment (ACAS) approvals?YesNo National Disability Insurance Scheme (NDIS)?YesNo How Did You Hear About Us? FAMILY/FriendsOnline BookingGoogleSignageOther If Other: This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose, treat and be pro-active in your health care needs. We may use the information you provide, in the following ways: • Administrative purposes in running our medical practice. • Billing purposes, including compliance with Medicare and Health Insurance Commission requirements. • Disclosure to others involved in your health care, including treating doctors and specialists outside this practice. This may occur through referral to other doctors, or for medical tests and in the reports returned to us following the referrals. • Disclosure to other doctors, allied health workers and nurses who may work in the practice, including Locums and Accreditation Surveyors, for the purpose of patient care, teaching and accreditation. • Disclosures for research and quality assurance activities to improve individual and community health care and practice management. This information will be de-identified. By signing this document below, I agree to the following: • I have read the information above and understand the reasons why my information must be collected. I am also aware that this practice has a privacy policy on handling patient information. • I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me. • I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances. • By completing the section below and providing a signature, I consent to the handling of my information by this practice for the purposes set out above, subject to any limitation on access of disclosure that I notify the practice of. • I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained. • I consent or decline as indicated to receive an SMS message regarding future appointments • I consent or decline as indicated to messages being left on telephone message service • I consent to register with my-medicare with HSM • Do you consent to the potential use of transcription software during your medical appointment for the purpose of accurate documentation and maintenance of your medical records Tap to sign here ↓ (required) Δ