Bendigo Medical
New Patient History
Registered By:
Your Details
Mr  Mast  Mrs  Miss  Ms 
First Name:________________________Initial___ Surname______________________D.O.B___/__/___
Address______________________________________________________________________________
_____________________________________________________________________________________
Ph. (Home) _________________Mobile_____________________Work___________________________
Email address__________________________________________________________________________
Medicare No____________________________Ref No.____Expiry Date__________________________
Pension Card  Consession card 
Card No__________________________________________Expiry date__________________
DVA No__________________________________ Gold Card Yes  No 
HAVE YOU REGISTERED YOUR BANK DETAILS WITH MEDICARE Yes  No 
Yes  No  Aboriginal or Torres Straight Islander:
Head Of Family First Name____________________Surname_____________________DOB___/___/___
Next of Kin Contact Details
Name___________________________Relationship_____________________________ DOB___/___/___
Address________________________________________________________________________________
_______________________________________________________________________________________
Ph.____________________________________ Mobile_________________________________________
Do you have any current Injuries/conditions: Yes  No 
If yes are the injuries/conditions
 Work Related. Do you have ongoing work cover claim? Yes  No 
 Motor Vehicle Accident. Do you have an ongoing TAC claim? Yes  No 
 Chronic condition. Describe____________________________________________
_____________________________________________________________________
 Other. Describe______________________________________________________
_____________________________________________________________________Have you had related
Surgery Yes  No 
Yes No
Female patients: Have you had a PAP Test in the last 2 years


Date of last PAP Test……………………………………………………….________________________
Do you have any of the following? (If yes briefly explain over page.)
Yes No
Yes No
Diabetes

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Allergies to Aspirin 
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Chest Pain / Angina
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Allergies to heat
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High Blood Pressure
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Allergies to cold
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Heart Disease
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Other Allergies
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Heart Attack
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Hernia
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Heart Palpitations
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Seizures
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Pacemaker

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Metal Implants

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Headaches

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Dizziness / Fainting 
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Kidney Problems

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Recent Fractures

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Are you Pregnant

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Surgery?

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Cancer

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Skin Abnormalities 
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Osteoporosis

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Sexual Dysfunction 
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Bowel Bladder Abnormalities

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Nausea / Vomiting 
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Urine Leakage

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Ringing in ears
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Asthma / Breathing difficulties
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Rheumatoid Arthritis 
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Liver / Gallbladder problems
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Smoking

Stroke/CVA

Other: ________________________ 
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Special Dietary needs 
Hypoglycaemia

HIV Positive

Other_____________ 
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If yes to any of the above please briefly explain
Is there any other information relating to your history we should know about
List any Medications you are currently taking
I accept that I am responsible for payment of all debts incurred at the Bendigo Medical Centre in my name
including all family members in my responsibility
I also accept that I am responsible for all accounts incurred for Insurance claims from either Work cover,
TAC or any other Insurance claims that are rejected by the relevant authority or organisation.
By signing this Form I acknowledge that I have read, understand and accept the above Statement of
conditions.
Signature_____________________________________Date_____/_____/____