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New Patient Information Form

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. You may fill in a hard-copy of this form at your first visit if preferred.

Surname

First Name/s

Date of Birth

Street Address

Mailing Address

Home Phone

Mobile Phone

Work Phone

Email

Medicare Number

Please include all 10 digits, plus the reference number beside your name

Medicare Card Expiry Date

Pension or Health Care Card holders:

DVA Gold Card Number

DVA White Card Number

Pension Card Number

Health Care Card Number

Expiry Date of Card

Emergency Contact . . . a person we can contact if necessary

Name

Phone Numbers

Please include a mobile number if available

Relationship

To assist with government health initiatives:

Are you of Aboriginal or Torres Strait Islander origin?

Yes No

Patient Consent

National Prescribing Service (NPS) clinical audits involve the doctor recording information on the treatment prescribed to patients with a particular illness. This information is anonymous. Your medical care will not be affected by your decision.

I have read and understood the information above and I agree to have my anonymous information included in any relevant NPS audits.

Yes, I agree No, I do not agree

Your Health History

Height in centimetres

Weight in kilograms

Do you have a history of

Asthma

Diabetes

Hypertension

Operations

Chronic illness

Other health problems

Details

e.g. Details of operations or chronic illness

ALLERGIES

Please list any allergies, or sensitivities to drugs or dressings, and your reaction.

IMMUNISATIONS

Tetanus Booster

Influenza

Pneumococcal

Hepatitis A

Hepatitus B

Polio

CHILDREN'S IMMUNISATIONS – If completing this form for a child, are all their immunisations up-to-date?

Yes No

CURRENT MEDICATIONS

Prescribed: Please list

Over the Counter: Please list

FAMILY HISTORY

Has any member of your family had:

Diabetes

Heart Disease

Cancer

Asthma

Mental Illness

SOCIAL HISTORY: Please answer any relevant sections

Smoking:

How many per day/week OR date ceased smoking

Alcohol:

Number of standard drinks per day/week/month

Drug use:

Type and frequency

BLOOD PRESSURE

When was the last time your blood pressure was taken? . . . Date / Approximate date / Not sure / Never

FOR THOSE 65 AND OLDER - when were you last immunised for:

. . . . . Influenza:

Date / Approximate date / Not sure / Never

. . . . . Pneumococcal pneumonia

Date / Approximate date / Not sure / Never

FEMALES - PAP SMEAR

When did you last have a Pap smear? . . . Date / Approximate date / Not sure / Never

FEMALES - BREAST CHECK

When did you last have a Breast check? . . . Date / Approximate date / Not sure / Never

MALES - OVERALL CHECKUP

When did you last have an overall checkup? . . . Date / Approximate date / Not sure / Never

39 Camp Street, Beechworth VIC 3747

(03) 5728 1566

admin@beechworthsurgery.com.au