Title: Surname: Given Name/s: Date of birth Gender: MaleFemale Marital Status: SingleMarriedDefactoSeparatedDivorcedWidowed Medicare No. Ref No. Exp. Date Pension, Health Care Card or DVA White/Gold Card Number Exp. Date Occupation Employer Home Address Postcode Postal Address Postcode Email Address Phone Home Work Mobile Next of Kin Name: Relation to you: Phone (mobile): (home): (work): Emergency Contact Name: Relation to you: Phone (mobile): (home): (work): To assist with health initiatives - are you Aboriginal or Torres Strait Islander? Yes - AboriginalYes - Torres Strait IslanderYes - Aboriginal & Torres Strait IslanderNo Do you identify as someone from a culturally and/or linguistic diverse background? Height Weight Allergy to medication or food? YesNo Please specify: Smoker Status Never SmokedEx-Smoker-Year quitSmoker Alcohol Intake NilYes Regular Medication NilYes Please list below any medications and their doses if known – include over the counter medications and supplements Current/Previous Medical Conditions NilYes AsthmaDiabetes Type 1 / Type 2Heart Attack (MI)Stroke/CVAPacemakerDVTEmphysemaDepression and/or AnxietyCancer (type)HIV/AIDSHepatitis A/B/CEpilepsyOther (please list) Family Medical History ---NilYes List Family Medical Histories Our practice undertakes research, professional development, and quality assurance/improvement activities to improve patient care. All people accessing personal health information for this purpose have signed a written confidentiality agreement. I consent to my health record being reviewed as a part of the quality improvement activities in this practice. YesNo I consent to my healthcare information being uploaded to My eHealth Record YesNo Our practice uses a reminder system to improve the quality of your health care. The practice sends reminders by mail or telephone for procedures such as vaccinations, pap smears and other health reviews. I consent to being contacted with reminders. YesNo I consent to being contacted by email. YesNo
