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.