Name : _____________________________________________________ DOB______________________
Address : ______________________________________________________________________________
________________________________________________________________ Postcode _____________
(H): ________________________ (M): __________________________ (W): ______________________
GP Details: ____________________________________________________________________________
Health Fund Name _____________________________________ Membership No: ___________________
Medicare Care No: _____________________________________ Patient Ref No _____ Expiry _________
Pension Card Holder YES / NO CRN _____________________________________ Expiry _________
IS THIS PROBLEM RELATED TO: Please circle appropriate answer
Work Cover YES / NO Employer Details : ______________________________
Third Party YES / NO
Legal Proceedings Pending YES / NO
Have you consulted a Solicitor YES / NO
If yes, Claim no ______________________________ Case Manager’s name _______________________
RIGHT OR LEFT HANDED: RIGHT LEFT
Occupation _____________________________ Main Duties ____________________________________
How did injury/complaint occur __________________________________________________________
PAST MEDICAL HISTORY PAST SURGERY
Procedure Year Diabetes
Any other illnesses _______________________________________________________________________
Known Allergies: ________________________________________________________________________
Do you smoke? Y / N How many / day________________________________
Do you drink Alcohol? Y / N If yes, how many standard drinks in 24hr period? ___________________
Regular Sports /Hobbies? _________________________________________________________________
The provision of quality health care requires a doctor-patient relationship of trust and confidentiality. Consistent with our commitment to quality care, this practice had developed a policy to protect privacy in compliance with the privacy legislation.
It is necessary for us to collect personal information from patients and sometimes others associated with their health care in order to attend to their health needs and for administrative purposes.
In the interests of the highest quality and continuity of the patient’s health care, this may also include sharing information from other health ca re provides who comprise a patient’s medical team from time to time.
This practice will also send a letter to all relevant health care providers including the referring medical practitioner detailing the treatment provided.
I have read the above information and give my consent.
Name of Patient
(Patient, Parent or Guardian)