KINGSCLIFF FAMILY MEDICAL
NEW PATIENT REGISTRATION FORM
Please PRINT and FILL IN
PATIENT NAME
Surname:
Given Names:
Name Title:
Mr ☐ Mrs ☐ Ms ☐ Miss ☐ Master ☐ Dr ☐
HEATH IDENTIFIERS
Medicare No.
☐☐☐☐☐☐☐☐☐☐
DVA No.
☐☐☐☐☐☐☐
Expiry Date ___ /___ /___
Expiry Date ___ /___ /___
Concession Card Number: ………………...................................................
HCC ☐ Pension ☐
Are you in a Private Health Fund? Yes ☐ No ☐ Name of Health Fund:…………………………………………………
PERSONAL DETAILS
Sex:
Male ☐ Female ☐
Date of Birth: ___ /___ /___
Elite Athlete: Yes ☐ No ☐
Nationality: Aboriginal ☐ Torres Strait Islander (TSI) ☐ ATSI ☐ Australian ☐ Other……………………………..
Marital Status: Single ☐ Married ☐ Divorced ☐ Separated ☐ De facto ☐ Widowed ☐
Next of Kin:
Full Name: ……………………………………………………… Relationship to Patient: ……………………
Address:…………………………………………………………………………Telephone No: …………………….
CONTACTS & EMPLOYMENT DETAILS
Home Address:……………………………………………………………………………………………………………………………………….
Postal Address (if different from home): ………………………………………………………………………………………………..
Telephone - Home:……………………………… Work: ……………………………… Mobile: …………………………
eMail: …………………………………………………….
Occupation:………………………………………………….Name of Employer:……………………………………………………….
Employer Address:…………………………………………………………………………………………………………………………………..
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KINGSCLIFF FAMILY MEDICAL
NEW PATIENT REGISTRATION FORM
Please PRINT and FILL IN
FAMILY HISTORY
To help us with providing quality health care to all our patients, we ask if you could please answer the following
questions:
Is there any family history of:
If yes, which family member(s)?
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Bowel cancer?
Breast cancer?
Diabetes?
Heart Disease?
Any other type of cancer?
Blood disorders?
Asthma?
Other?.............................
Yes ☐ No ☐ ……………………………………………………………………………………………….
Yes ☐ No ☐ ……………………………………………………………………………………………….
Yes ☐ No ☐ ……………………………………………………………………………………………….
Yes ☐ No ☐ ……………………………………………………………………………………………….
Yes ☐ No ☐ ……………………………………………………………………………………………….
Yes ☐ No ☐ ……………………………………………………………………………………………….
Yes ☐ No ☐ ……………………………………………………………………………………………….
Yes ☐ No ☐ ……………………………………………………………………………………………….
MEDICATIONS AND PAST MEDICAL HISTORY
Please list any medications you are taking (including herbal products):
Past Medical Condition
Year Diagnosed
Operations:
Year
Do you have any allergies? Yes ☐ No ☐ If yes please list below:
SOCIAL HISTORY
Are you a smoker?
Yes ☐ No ☐ If yes, how many cigarettes per day? ………….
Have you ever smoked?
Yes ☐ No ☐ If yes, year started………… Year stopped……….
Do you drink alcohol?
Yes ☐ No ☐ If yes, how many days per week do you drink alcohol?..............
How many standard drinks would you drink per day?..........................
How often do you ever drink more than 6 drinks per day? Never ☐ Daily ☐ Weekly ☐ Monthly ☐
Do you live alone? Yes ☐ No ☐ If no, who do you live with? ………………………………………………………………..
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KINGSCLIFF FAMILY MEDICAL
NEW PATIENT REGISTRATION FORM
Please PRINT and FILL IN
FEMALE PATIENTS
Have you ever been pregnant? Yes ☐ No ☐ if yes, how many times?..................
How many children do you have?………………
When was your last pap smear?………………. Result: Normal ☐ Abnormal ☐ Unsure ☐
Have you had a mammogram? Yes ☐ No ☐ Year?................
Are you using some form of contraception? Yes ☐ No ☐
If yes, please specify: …………………………………………………………………………………………………………………………………..
Are you taking hormone replacement therapy? Yes ☐ No ☐
If yes, please specify: …………………………………………………………………………………………………………………………………..
IMMUNISATION HISTORY
ADULTS: Please tick vaccinations (if known)
☐ Flu vax ☐ Pneumonia ☐ Tetanus ☐Hepatitis A ☐ Hepatitis B ☐Other …………………………
CHILDREN: Have they received all the scheduled vaccinations (0-4 years)? ☐ Yes ☐ No ☐ Unsure
Are you a conscientious objector to immunisations? ☐ Yes ☐ No
PATIENT CONSENT
This Medical Practice collects your personal information for the primary purpose of providing quality health
care. We require you to provide us with your personal details and a full medical history to allow us to properly
assess, diagnose, treat and advise on all your health care needs. Please place a tick in the following boxes if you
give consent for this information to be used by the Practice in the following ways:
☐ I give permission for my personal health information to be used for administrative purpose to assist in the
running of this Medical Practice, including disclosure to other involved in my healthcare, such as treating doctors
and specialists within and outside this Medical Practice. This may occur through referral to other Doctors, or for
medical tests and in the reports or results returned to my doctor following referrals.
☐ I give my consent for disclosure for research and quality assurance activities to improve individual,
community health care and Practice management. This may occur when the Practice incorporated patient health
records into de-identifiable patient information to transfer to a third party, normally used for quality
improvement projects. De-identifiable patient information cannot be traced back to the individual.
☐ I give my consent to the presence of a third party to be present during my consultation. This may include a
Practice Nurse or a Medical Student.
☐ I give my consent to be part of the Practice’s National, State and Territory recall and reminder systems.
I understand by ticking the relevant boxes above that the Practice is authorized on my behalf to use my relevant
personal health information, and I am free to withdraw my consent at any time by verbal or written notification.
NAME: …………………………………………………………………………...Please tick: ☐ Self ☐ Parent ☐ Guardian (if under 18)
SIGNATURE:…………………………………………………………………….Date: ___ /___ /___
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