Top Health Doctors Integrity Service Excellence Units 8-10, 2770 Logan Road, Underwood Qld 4119 Tel: (07) 3133 0822 Fax: (07) 31626281 Website: www.tophealthdoctors.com.au We need this information to provide you with the best quality of care. Our practice follows the guidelines of The Royal College of General Practitioners handbook for the management of health information in private medical practice. This means that your personal health information is kept private and secure, as required by federal privacy laws. Title: ____ Given Name: __________________Surname: _______________________________________ Known as: _____________________ Date of Birth: ____/______/_____ Female ⃝ Male ⃝ Address: _______________________________ Suburb: ______________ Postcode: _________________ Phone: (H)______________________ (W)____________________ Mobile_________________________ Email address: _________________________________________________________________________ Single ⃝ De facto ⃝ Married ⃝ Occupation: __________________________ Ethnic Origin: Separated ⃝ Divorced ⃝ Widowed ⃝ Country of Birth: ____________________________________ Caucasian ⃝ Asian ⃝ Aboriginal ⃝ Torres Strait Islander ⃝ Other ⃝_________________ Australia is a multicultural society – knowing your ethnic background will help us tailor specifically to your health care needs. Medicare number Reference number Expiry / (Number beside your name) Pension / HealthCare (circle one): Expiry Veterans Affairs Card (Month/Year) / / Colour(circle one): Gold / White Next of Kin: Name: _____________________ Surname: ______________________________________ Phone: (H) ___________________ Mob: ________________________Relationship: ______________________ What are you allergic to: ______________________________________________________________________ Please list any current medications (including over the counter medicine and vitamins) _____________________ ___________________________________________________________________________________________ Do you drink alcohol Yes ⃝ No ⃝ How much _____ Daily / Weekly / Monthly / Socially Do you smoke Yes ⃝ No ⃝ How much _____ Daily / Weekly / Monthly / Socially Social History: Please include any sports, hobbies and other interest: ___________________________________ ___________________________________________________________________________________________ How did you hear about this practice? ⃝ Google ⃝ Yahoo ⃝ Yellowpages Online ⃝Others_________ ⃝ Search Term____________________________________ ⃝ Other, please specify ⃝ Street Signage ⃝ Other Medical Centre ⃝ Word of mouth ⃝ Yellow Pages in print ⃝ Chemist ⃝ White Pages _____________________________ PLEASE TURN OVER Patient Medical History: Please list any current or past medical conditions or operations Condition Asthma Diabetes Blood Pressure Cancer (Type) Others Yes No Condition Heart disease Heart attack Stroke Bleeding disorder Yes No Operation Skin Cancer Appendix Gallbladder Orthopaedic Yes No Family Medical History: Please list any of the following conditions in your family Condition Heart Disease / attack Stroke Diabetes Breathing problems Others Yes No Who Condition Bleeding disorder Cancer (type) Psychiatric Genetic Disorder (type) Signature of Patient or Guardian: ______________________________________ Yes No Who Date: ___/_____/ __________ Patient Privacy Information: To provide a high standard of medical care, we need to collect personal information from our patients. This information is usually collected from the patient but may be collected from family and other health care providers with the patient’s consent. At times, some of this information needs to be shared with other health care providers or we may be legally bound to disclose personal information. From time to time, your consult may include the presence of a medical student or GP registrar as our doctors are actively engaged in teaching trainee doctors. All persons accessing your personal health information are bound by confidentiality. Please do not hesitate to discuss any concerns, questions or complaints about any issues related to your privacy of your personal information with your doctor. Please note our cancellation/non-attendance policy: Appointments require at least 1.5 hours’ notice to cancel an appointment that has been made. Failure to cancel an appointment will incur a $30.00 non-attendance fee. Cancelling appointments that you cannot make allows time for other patients who need to see a Doctor. We thank you for your cooperation. Thank you for your time taken to complete the Patient Form. Please E mail this form to reception@tophealthdoctors.com.au or fax it to Fax number (07) 31626281.