MERLYNSTON VILLAGE MEDICAL CENTRE PATIENT HEALTH SUMMARY
Once completed, please hand to the receptionist.
HOW DID YOU HEAR ABOUT US  INTERNET
 FRIEND/FAMILY
NEWSPAPER OTHER…………………………………………………..
Title
Name
 HEALTH ENGINE
 PHARMACY
Surname
Date of birth:
 Male
 Female
MEDICARE NO:
REF:
Do you have a Health Care Card
EXPIRY:
Card no.
Expiry date:
 DVA card  Pension Card
ETHNICITY:_________________
 Aboriginal
 Torres Strait Islander
Home address
 Aboriginal and Torres Strait Islander
 NON ATSI
Work address
Postcode
Phone: (H)
Postcode
Phone: (W)
Phone: (M)
EMAIL:
Marital Status: Single
 Married  Divorced
Country of Birth
 Separated
 Widowed
 Defacto
Citizenship
EMERGENCY CONTACT
Name:
______________________________________
Phone: (H)
Address:
Phone: (W)
Relationship:
Please note! In an emergency your
contact nominated person may be given information
relating to your health
_____________________________________
Address:
Phone: (M)
______________________________________
Phone: (H)
Next of Kin:
_______________________________
Phone: (W)
If different to above
Phone: (M)
Relationship:
PATIENT PRIVACY: 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 also from family members and other health care providers. At times some of this information needs to be shared with doctors auditing our medical
records as part of the RACGP accreditation process and other health care providers or we may be legally bound to disclose personal information. All persons
accessing your health information are bound by confidentiality. Please do not hesitate to discuss any concerns, questions or complaints about any issues related to
the privacy of your personal information with your Doctor.
RECALLS AND REMINDERS: At times we may elect to contact you via SMS to remind you of health related recall or reminder appointments, are you happy for us to
communicate with you in this manner. I give permission for MERLYNSTON VILLAGE MEDICAL CENTRE
to contact me via SMS Yes No
Practice Information Brochure If you are a new patient please ask at reception for a copy of our Practice Information Brochure.
Patient or Guardian Signature:
Date:
Past Medical History
Have you suffered from any of the following – currently or previously?
□ Heart problems
□ Stroke
□ High blood pressure
□ Blood clots
□ Glaucoma
□ Epilepsy
□ Anxiety / depression
□ Asthma
□ Bronchitis
□ Diabetes
□ Back Pain
□ Eye problems
□ Thyroid problems
□ Hep C
□ Hep B
□ Liver disease
□ Kidney disease
□ Osteoporosis
□ Fractures
□ Arthritis
□ Hearing loss
□ Migraines
□ Skin conditions
□ Cancer
□ High Cholesterol
□ HIV
□ Any other ________________________________________________________________________
Preventative health: Please tick the boxes where appropriate
ALL
Bowel screening □ Date
Skin Check
□ Date
Unintended weight change
________KG
FEMALES
Pap smear
□ Date
Mammogram □ Date
Health check □ Date
Last
_____
Immunisation
_____
□
since (date) ____________
MALES
Any illnesses, operations or
hospital admissions and year
Prostate check
Testis check
Health check
Last
Immunisation
----------
□ Date
□ Date
□ Date
________
________
MEDICATIONS AND SOCIAL HISTORY:
Please include ALL tablets, inhalers, patches, gels or injections as
well as any “natural” remedies or supplements.
SMOKER  __________________per day
 QUIT IN _________________
EX-SMOKER
CURRENT MEDICATIONS
DOSE
NON SMOKER 
FREQUENCY
ALCOHOL_______days per week____________drinks per day
Non-drinker

Recreational drugs  Specify_______________________________
 Independent  Requires assistance
Occupation:
FAMILY HISTORY
MOTHER
living
FATHER
living
SIBLINGS
_________
Heart attack
Bowel cancer
Breast cancer
High blood pressure
Stroke
Arthritis
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Blood clot/s
Depression
Diabetes
Thyroid disease
Hemochromatosis
Osteoporosis
Other:
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ALLERGIES
 Nil Known
_____________
_____________
_____________
_____________
_____________
_____________
_____________
Any other health concerns? _________________________________________________________________
The information I have provided in this questionnaire is correct, complete and without any major omissions to the best of my knowledge.
First Name: _____________________________________ Surname: _______________________________Date _______________
Patient or Guardian Signature (required for minors or dependants)___________________________________________________________