NEW PATIENT REGISTRATION FORM
NEW PATIENT REGISTRATION FORM Mr Mrs Ms Miss Dr Surname ………………………………………. First Name…………………………. Date of Birth………………….. Postal Address………………………………………………………………………………………………….. ……………………………………………………………………………………………………………………… Day Time Phone………………………… Mobile………………………… Wk………………….. Email address: ………………………………………………………………………………………………………… Emergency Contact Person………………………. Relationship to you…………………. Contact phone No (mobile)………………………. Home…………………………………. Are you Aboriginal Torres Strait Islander Non Indigenous Medicare No …………………………. Ref No next to name………………… Or Vet Affairs No …………………………. Expiry…………. Pension / Health Care Card Number………………………… Expiry…………… Full time Student card number.……………………………… To whom should the account be addressed if the patient is a child Please hand this page to Reception. Please complete pages 2 and 3, and take into doctor. Expiry…………….. MEDICAL INFORMATION PATIENT NAME: PATIENT D.O.B ALLERGIES Nil known □ Please list any allergies ……………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………….. PLEASE LIST ANY PAST MEDICAL / SURGICAL HISTORY Heart Disease High cholesterol Cancer Stroke Asthma Epilepsy High Blood Pressure Diabetes Migraine Blood clots Stomach or duodenal ulcer Depression / Anxiety Other illness / surgery – please give details ………………………………………………………………………. Please list current medications including vitamins and mineral supplements ...…………………………………. ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… IMMUNISATIONS (please tick relevant boxes) Pneumococcal (pneumonia) Influenza Tetanus Childhood vaccines up to date Other (please specify) …………………………………………………… ………………………………………………………………………………………………………………………………….. -2- MEDICAL INFORMATION PATIENT NAME: PATIENT D.O.B FAMILY HISTORY Do you have a family history of Diabetes Heart disease Stroke Asthma Genetic/ inherit disorder Cancer Mother Mother Mother Mother Mother Mother Father Father Father Father Father Father Brother/Sister Brother/Sister Brother/Sister Brother/Sister Brother/ Sister Brother/Sister Grandparent Grandparent Grandparent Grandparent Grandparent Grandparent If there is a family history of cancer, please specify what kind: ………………………………………… LIFESTYLE HEALTH HISTORY Smoking history:- Alcohol:- Never Former smoker – quit date Current smoker - /day Number of years smoking Do you drink alcohol yes no Drinks per day ………… Drinks per week ……… . WOMEN’S HEALTH (specify approx month/year) Last pap smear…………………… Last mammogram……………… MEN’S HEALTH Last prostate check (if aged over 40)……………………. INFANT PROFILE Please list any problems during pregnancy? ……………………………………………………………. When was the baby born? □ Full Term □ Premature, if yes how many weeks? …………………………………………………………………… Mode of delivery □ Normal □ Forceps □ Caesarean □ Vacuum extraction Were there any health problems for the baby after birth? ……………………………………………… Feeding? □ Bottle □ breast fed Are there any smokers in the household? …………………………………………………………………. -3-
© Copyright 2024