It is essential that your health record contains complete and accurate information to provide quality care. Please assist us by filling out this new patient record form. Your personal health information is kept private and secure as required by federal and state privacy.

Birth Sex: *

MaleFemale

Gender Identification *

Preferred Pronouns: *

Ethnicity: *Knowing your cultural background helps us provide health care that meets your individual needs.

Do you identify as Aboriginal and/or Torres Strait Islander? *

Address: *

Residential address *

Suburb *

State *

Postcode *

Preferred Contact Method: *

Medicare Number: *Please note this is the 10 digit card number. If you do not have a Medicare card please list a 10 digit number.

Medicare Reference Number (number next to your name): *

Medicare Card Expiry Date: *

Concession Card CRN:

Consession Card Type

Private Health Fund:

Private Health Number:

Is your NOK the same as your emergency contact?

EMERGENCY CONTACT (if different from above):

Emergency Contact Full Name:

Emergency Contact Mobile Number:

Emergency Contact Relationship:

PRIVACY PATIENT INFORMATION

Patients Signature: *

Draw signature|Type signatureClear

* Other - Please Specify

Please list the medication name, strength, dose and reason for taking the medication: *If you do not take any medication please list NA.

Please list any allergies to medication or any other significant allergies: *If you do not have any allergies please list NA.

Current smoking history *

Non-smokerEx-smokerSmokerVaper

If yes, please advise how many cigarettes per day or how much vape per day:

Current alcohol intake: *

Non-drinkerEx-drinkerDrinker

If yes, please advise how many standard drinks per day/ per week:

CURRENT/ PAST HEALTH PROBLEMS

SIGNIFICANT FAMILY HISTORY

If "other" selected, please list:

Please list any past surgeries or operations:If you have not had any surgeries or operations please list NA

Have you had any imaging? (X-ray, CT Scans, MRI's, Ultrasounds, Bone Scans and/ or other?)If you have not have any imaging please list NA

Date of last Cervical Screening Test:

Any abnormal cervical screening tests in the past:

YesNo

Are you pregnant

YesNoUnsure

Form of contraception (if any):

NEW PATIENT FORM

PERSONAL DETAILS

HEALTH COVER

NEXT OF KIN

EMERGENCY CONTACT (if different from above):

PRIVACY PATIENT INFORMATION

MEDICAL HISTORY

MEDICATION LIST

ALLERGIES

CURRENT/ PAST HEALTH PROBLEMS

SIGNIFICANT FAMILY HISTORY

GENERAL

FOR WOMEN