New Patient Information Form
We are committed to providing our patients with the best care, to do this it is essential that your medical
records are up to date and accurate.
* FIRST NAME
* SURNAME
* MRS
MS
MR
* DATE OF BIRTH
* MEDICARE NUMBER
Ref No.
*DVA Gold / White
Expiry Date
Expiry Date
(Please Circle)
* CONCESSION CARD eg: Pension/HCC/Seniors HCC
Ref No.
Expiry Date
* RESIDENTIAL ADDRESS
* POSTAL ADDRESS
* HOME PHONE
WORK PHONE
MOBILE
EMAIL
MARITAL STATUS
OCCUPATION
COUNTRY OF ORIGIN
* DETAILS OF YOUR NEXT OF KIN or EMERGENCY CONTACT
* NAME
* RELATIONSHIP TO PATIENT
* ADDRESS
* PHONE NUMBER
DO YOU REQUIRE AN INTERPRETER SERVICE
Yes
No
Are you of Aboriginal origin?
Yes
No
Torres Strait Islander origin?
Yes
No
TO ASSIST WITH HEALTH INITIATIVES:
Reminder Systems:
Our practice provides our patients with preventive care and early case detection reminders, e.g. immunisations,
annual health checks, skin checks and pap smears.
Do you wish to have any relevant health reminders sent to you?
Yes
No
Do you have any allergies or are you sensitive to drugs or dressings:
Yes (If yes please list below)
No
__________________________________________________________________________________
Your Health History - Do you have or had a history of?
Operations
______________________________________
Asthma
______________________________________
Diabetes
______________________________________
Hypertension
______________________________________
Chronic Illness
______________________________________
Other
______________________________________
Immunisations - Have you had the following immunisations?
Tetanus booster Date______________________________ Dont Know
Hepatitis B
Date______________________________ Dont Know
Hepatitis A
Date______________________________ Dont Know
Influenza
Date______________________________ Dont Know
Pneumococcal
Date______________________________ Dont Know
Polio
Date_____________________________
Dont Know
Havent had one
Havent had one
Havent had one
Havent had one
Havent had one
Havent had one
Childrens Immunisations - If completing this form for a child is their immunisations up to date?
Yes
No
Current Medications (including over the counter medications, vitamins and minerals)
___________________________________________________________________________________________
___________________________________________________________________________________________
________________________________________________________________
Family History - Has any members of your family had?
Diabetes
Heart Disease
______________________________________
______________________________________
Asthma
Mental illness
______________________________________
______________________________________
Cancer
______________________________________
Social History
Tobacco:________________________day / week or Ceased Smoking date__________________________
Alcohol: _______________________ day / week / month (circle the one applicable)
Drug use_____________________________________________________ (type and frequency)
Height: __________ cms
Weight: _____________ kgs
Blood Pressure: When was the last time your blood pressure was taken? _____________________________
For those 65 years and older: When was the last time you were immunised?
Influenza
Date___________________________
Pneumococcal pneumonia
Date___________________________
Females: When did you last have?
Pap smear
Date___________________________
Males: When did you last have?
An overall check up
Date ___________________________
not sure
not sure
never
never
not sure
never
not sure
never
Patients Signature or Parent / Guardian (if child is a minor)
