NEW PATIENT FORM

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.

PERSONAL DETAILS

Title: *

Given Name(s): *

Surname: *

Date of Birth: *

Birth Sex: *

MaleFemale

Gender Identification *

Preferred Pronouns: *

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

Country of Birth: *

Preferred Language:

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

Address: *

Residential address *

Suburb *

State *

Postcode *

Mobile Number: *

Home Phone:

Email Address *

Preferred Contact Method: *

HEAD OF FAMILY

Head of Family Title: *

Head of Family Given Name(s): *

Head of Family Surname: *

Head of Family Date of Birth: *

Head of Family Birth Sex: *

Male Female

Head of Family Address: *

Residential address *

Suburb *

State *

Postcode *

Head of Family Mobile Number: *

Head of Family Home Phone:

Head of Family Email: *

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

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

Head of Family Medicare Card Expiry Date: *

Head of Family Concession Card CRN:

Head of Family Concession Card Type:

HEALTH COVER

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

Expiry Date:

DVA Number:

DVA Card Type

DVA Conditions

Private Health Fund:

Private Health Number:

NEXT OF KIN

Full Name: *

Mobile Number: *

Relationship: *

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

Date: *

Full Name: *

Patients Signature: *

Draw signature|Type signatureClear

* Other - Please Specify

MEDICAL HISTORY - CHILD

(under 16 years)

As a new patient, completing this form helps us get a detailed overview of your child's health. This form is confidential and will only be kept in their individual confidential medical record.

If possible, please bring bring to your initial consultation:

Records of childhood (and travel) vaccinations
Child Health Record (for pre-school children or if otherwise relevant)
Asthma Management Plan (if relevant)

CURRENT/ PAST HEALTH OR DEVELOPMENTAL PROBLEMS

Any major problems during pregnancy or soon after birth *

YesNo

Spina bifida *

YesNo

Skin problems: eczema/ seborrhoeic dermatitis/ other *

YesNo

Cerebral palsy *

YesNo

Diabetes *

YesNo

Autism/ aspergers *

YesNo

Vision or eye problems *

YesNo

ADHA or behavioural disorder *

YesNo

Deafness or concern about hearing *

YesNo

Anxiety/ depression/ obsessive-compulsive disorder/ other mental health problem *

YesNo

Recurrent ear infections *

YesNo

Teeth/ gum problems *

YesNo

Asthma / other lung problems *

YesNo

Does your child see a dentist regularly *

YesNo

If Asthma: does your child have a current Asthma Management Plan

YesNo

Concerns about bed-wetting

YesNo

Coeliac disease/ lactose intolerance / other malabsorption *

YesNo

Other toileting concerns *

YesNo

Seizures/ epilepsy *

YesNo

Constipation *

YesNo

Kidney problems/ recurrent urinary infections *

YesNo

Concerns about speech and language development *

YesNo

Cancer/ leukemia *

YesNo

Learning difficulties *

YesNo

Arthritis *

YesNo

Concerns about other aspects of development *

YesNo

Unusual or severe infection/ menigitis *

YesNo

Concerns about obesity *

YesNo

Mirgraine or severe headache *

YesNo

Operations/ surgery *

YesNo

Head injury *

YesNo

If yes please list operations/ surgeries

CLINICAL INFORMATION

Have any other family members had any of the following:

Anxiety/ depression/ suicide: *

YesNo

Asthma/ eczema/ hay fever: *

YesNo

Childhood or early adulthood cancer (including: skin cancer): *

YesNo

Hereditary conditions or those detected at birth or that run in the family: *

YesNo

Types:

Additional information

Other serious childhood illness your are concerned about: *

YesNo

Some clinical problems are more (or less) likely to occur in people of particular ethnic backgrounds. If you wish us to be aware of your child's ETHNIC ORIGINS, please record here:

MEDICATION

Please list any medication, the strength, dose and reason for taking medication:If there are no medications please write NA

ALLERGIES

Please list any allergies to medications or other significant allergiesIf there are no allergies please write NA

CARE ARRANGEMENTS

Please advise who the child primarily lives with (mum/ dad/ both parents/ stepmother/ stepfather/ foster parent etc): *

Please list the name and relationship of any other parent/ carer that the child lives with or is involved with: *