New Patient Information Form – Lowood
We are committed to providing our patients with the best care, to do this it is essential that your
Medical Records are up to date and accurate.
Could you please assist us by completing the following Mr / Mst / Mrs / Ms / Miss
Name Known as:
DATE:
/
/ 20
Marital Status:
Single / Married
De facto / Divorced / Widowed
(Please Circle)
Surname:
SEX: M / F
First Name:
Middle Name:
Date of Birth:
Country of Birth:
Street Address:
Suburb and Post Code:
Home Phone:
Mobile Phone:
Occupation:
Work Phone:
Medicare Number:
(Patient No):
Expiry Date
DVA Gold / White:
Expiry Date
(Please Circle)
Pension Number:
Expiry Date
Health Care Card Number:
Expiry Date
Private Health Cover:
Membership No:
Next of Kin:
Relationship:
(Name and Phone Number)
Emergency Contact:
(If different from Next of Kin)
(Name and Phone Number
of a person we can contact)
Reminder Systems:
Our practice provides our patients with preventive care and early case detection reminders, e.g.
immunisations, annual health checks, skin checks and pap smears. We also employ a nurse for chronic
disease management.
Do you wish to have relevant health reminders sent to you (from our Practice only) regarding
your healthcare?
Yes
No
Do you identify with any particular culture? (If Yes, please specify below)
__________________________________________________________________________________
To assist with health initiatives please indicate the following:
Non-Indigenous
Aboriginal
Torres Strait Islander
Aboriginal & Torres Strait Islander
Your Health History - Do you have or had a history of?
Operations (If any, please list Year & Type Performed)
__________________________________________________________________________________
Asthma
__________________________________________________________________________________
Chronic illness
__________________________________________________________________________________
Diabetes
__________________________________________________________________________________
Hypertension
__________________________________________________________________________________
Other
_________________________________________________________________(Please Turn Page):
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New Patient Information Form – Lowood
Do you have any Allergies or are you Sensitive to Drugs or Dressings:
Yes (If yes, please list below & Type of Reaction)
No Known Allergies
__________________________________________________________________________________
__________________________________________________________________________________
Immunisations - Have you had the following immunisations?
Tetanus booster date_________
Don’t Know
Hepatitis B
date_________
Don’t Know
Hepatitis A
date_________
Don’t Know
Influenza
date_________
Don’t Know
Pneumococcal
date_________
Don’t Know
Polio
date_________
Don’t Know
Haven’t had one
Haven’t had one
Haven’t had one
Haven’t had one
Haven’t had one
Haven’t had one
Children’s Immunisations - If completing this form for a child is their immunisations up to date?
Yes
No
Current Medications (including over the counter medications, vitamins and minerals):
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Family History - Has any members of your family had?
(Please specify whether Mother / Father / Sister / Brother, etc)
Asthma
__________________________________________________________________________________
Cancer
__________________________________________________________________________________
Diabetes
__________________________________________________________________________________
Heart Disease
__________________________________________________________________________________
Mental illness
__________________________________________________________________________________
Other
__________________________________________________________________________________
Social History
Tobacco: ________ day / week or Ceased Smoking - date ____________
Alcohol: ________ day / week / month (circle the one applicable)
Drug use: _____________________________________________________ (type and frequency
Blood Pressure: When was the last time your blood pressure was taken?
__________________________________________________________________________________
CONSENT FOR USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION:
I consent to the use of my personal health information by the abovenamed practice and other health
providers involved in my medical treatment and healthcare.
I consent to the disclosure of my personal health information by the abovenamed practice and other
health providers directly or indirectly involved in my personal health care or medical treatment.
………………………………………………………………………………………………………………………...
Patient Name
Signature
Date
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