PATIENT DETAILS
Family Name
Given Name(s):
Parent/Guardian(if
under 18 years):
Residential
Address
Postal
Address
Date of Birth
Contact:
Next of Kin
Second Next of Kin
Language Spoken
(if not English)
Do you have Private
Health Insurance?
YES / NO
Government Pension
or Health Care
Benefits ?
YES/NO
Medicare No.
Mr/Mrs/Ms/Miss/Dr/Rev
Postcode:
.
Postcode:
.
Home Ph:
Work Ph:
Mobile:
Email:
Name:
Contact Phone
Relationship
Name:
Contact Phone
Fund:
Member No.
Level
Date joined:
Type: AGE / HEALTH CARE CARD /
VET AFFAIRS
Number
Expiry Date
__ __ __ __ __ __ __ __ __ __
Position Number: ___
Expiry Date: ___ / ___
Is this visit related
to a WorkCover or
Motor Accident claim?
YES/NO
Date of Accident:
Claim No.
Employer/Insurer
Address
Contact Person
Contact Phone
Family/Local
General Doctor
Name
Clinic Name
Street
Suburb:
Phone:
P/code
Melbourne Retina Associates
Suites 402 to 406, 100 Victoria Parade
East Melbourne, 3002
Phone: 03 9650 4771
Fax: 03 9650 1776
Email: reception@melbourneretina.com.au
www.melbourneretina.com.au
Optometrist
(person who makes
glasses)
Diabetic
Specialist
(if applicable)
Have you ever had
the following
complaints?
General
Health
Name:
Clinic Name
Street
Suburb:
Postcode
Phone:
Name:
Clinic Name
Street
Suburb:
Postcode
Phone:
MEDICAL HISTORY
Anaemia
Arthritis
Asthma
Bronchitis/
Emphysema
Back or neck problems
Blood clot on lungs/legs
Diabetes
Eczema/Dermatitis
Hayfever
Heart Disease
Hepatitis or Jaundice
High Blood Pressure
Kidney Disease
Lung Disease
Pneumonia
Rheumatic Fever
Shortness of Breath
Sleep Disorders
Stress related conditions
Stroke
Tuberculosis
Other
YES
YES
YES
YES
/
/
/
/
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Do you currently smoke?
History of past smoking.
No. per day
Melbourne Retina Associates
Suites 402 to 406, 100 Victoria Parade
East Melbourne, 3002
Phone: 03 9650 4771
Fax: 03 9650 1776
Email: reception@melbourneretina.com.au
www.melbourneretina.com.au
OPERATIONS
Have you ever had
surgery?
YES/NO
If yes please list.
Have you had:
YOUR EYE HISTORY
Cataracts
YES/NO
Retinal Detachment
Glaucoma
Diabetes
Other Eye Disease
YES/NO
YES/NO
YES/NO
YES/NO specify if yes
FAMILY EYE HISTORY
Have any of
your Grandparents,
Parents, brothers or
sister had:
Cataracts
Retinal Detachment
Glaucoma
Diabetes
Other Eye Disease
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO specify if yes
Melbourne Retina Associates
Suites 402 to 406, 100 Victoria Parade
East Melbourne, 3002
Phone: 03 9650 4771
Fax: 03 9650 1776
Email: reception@melbourneretina.com.au
www.melbourneretina.com.au
Current Medications
This includes tablets/
injections
Drug
MEDICATIONS
Dose Frequency
and eye drops
Are you allergic to any
drugs?
Drug
YES/NO
PLEASE READ AND SIGN BELOW
DISCLAIMER:
Under the provision of the Privacy Act written consent may be obtained to
disclose your personals details to third parties.
You personal information may be provided to referring practitioners,
diagnostic and hospital departments or treating specialists who are directly
involved with your health management.
Additionally, failure to pay accounts within 60 days may result in personal
details being forwarded to a debt collection agency.
__________________________________Date_______/________/________
Patient Signature
Melbourne Retina Associates
Suites 402 to 406, 100 Victoria Parade
East Melbourne, 3002
Phone: 03 9650 4771
Fax: 03 9650 1776
Email: reception@melbourneretina.com.au
www.melbourneretina.com.au