YOUR MEDICAL CLINIC
PATIENT HEALTH SUMMARY
In order for you and your doctor to work together to achieve the best possible health outcomes, it is
important that the doctor understands you as more than just a patient with an illness.
At this Practice, we would be grateful if you and your doctor could complete the accompanying
Patient Health Summary together, so that the doctor understands your physical, emotional, and
social settings. With this information up to date, more appropriate appointments, treatments,
investigations and follow up can be negotiated by you and your doctor to maximise your wellbeing.
Patient to complete
Your Name: (Also preferred
name if applicable)
Date of Birth
Medicare number
Pension/Repat
Private Health Fund Details
Phone number to reach you
on or other preferred method
of contacting you.
Residential address:
Postal address: (if different to
residential)
Phone number: Home &
Mobile
EMAIL address:
Other Immediate Family
Members attending this
Practice & relationship to you
(eg:step child/defacto)
Any Custody Issues
Emergency Contact
How long have you been a
Patient at this practice?
Living arrangements;
eg: live alone/with husband/
family/ parents
Transport to the practice:
eg Self/public/family/taxi
Do you need a ramp or
disabled facilities?
Are you Vision or Hearing
impaired?
Special considerations:
eg:No blood products/
Donate body to
science/organ donor
Employment/occupation
Any current Claim numbers:
eg: TAC/Workcover
Do you use any community
services?
eg:Hospice/ CAT
Team/Meals on wheels
Please Turn the page
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Doctor
Patient to complete
Doctor
Cigarettes:
eg Never / ex-smoker
(since) / Current (number
per day)
Alcohol:
eg Days per week/ number
per day/ type
Allergies proven
Immunizations:
eg last booster / routine
childhood immunisation.
(Tetanus? Hepatitis? Flu?
Pneumonia)
Parents please bring
immunisation record to
every visit with your child.
Height and Weight (note
any recent changes to
weight)
Past Medical Conditions:
Note the approximate year
& names of any
specialists/hospittals
involved
Family History of note: eg
Cancer/heart attack/long
healthy lives/diabetes
Ongoing Medical
Conditions: eg:high
BP/Depression/ arthritis
Current Medications
prescribed by doctor
Other substances being
used at present:
eg Naturopathic/
recreational
Social history:
eg activities/clubs/ sports
Recent Medical Tests (last
6 months)
eg Colonoscopy/
mammogram/blood
Regular medical tests due
within the next 12 months:
eg:PAP smear/ cholesterol
test.
I ………………………………………………….., date…………………… consent to this practice
transferring this information to other Health Providers for the purpose of my ongoing
medical management, or for use in Practice Enhancement Activities (information will be
deidentified wherever possible when used for Practice Enhancement).
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