Top Health Doctors Integrity Ÿ Service Ÿ Excellence Units 8

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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
Pension / HealthCare / Veterans Affairs Card
Expiry
/
/
Expiry
/
/
/
Emergency Contact: Name: _____________________ Surname: ______________________________________
Phone: (H) ___________________ Mob: ________________________Relationship: ______________________
Next of kin _________________________________________Phone:___________________________________
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____________________________________
⃝ Street Signage
⃝ Word of mouth
⃝ Chemist
⃝ Yellow Pages in print
⃝ White Pages
⃝ Other Medical Centre
⃝ Other, please specify
_____________________________
PTO
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)
Yes
No
Who
We endeavour to bulk bill all patients. However, sometimes, there will be a small gap fee for some selected
services. Please fill in the Online Claiming details to facilitate your online claiming.
BSB_______________________ Account Number____________________________________________________
Name on Account ___________________________
Name of bank___________________________________
Would you like us to save those details for future transactions
Signature of Patient or Guardian: ______________________________________
⃝ Yes
⃝ No
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.
Thank you for your time taken to complete the Patient Form.
Please E mail this form to [email protected] or fax it to Fax number (07) 31626281.
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