Patient Registration
Please complete all sections
	
Please circle:		Mr	Mrs	Ms	Miss	Master		
First Name:			Surname:		
Date of Birth:			Birth Sex:	Female	Male	Other	
Gender Identity:	Female	Male	Non-Binary	Gender Diverse	Transgender	
Pronouns:	She/her/hers		He/him/hers		They/them/theirs	
Address:		
Suburb:		Postcode:		
Postal Address if different		Postcode		
Home Number:		Work Number:		
Mobile Number:		
Email Address:		
Country of Birth:				Ethnicity:		
Occupation		Place of Work:		
Language spoken? (if other than English)			

Are you of Aboriginal Origin?  Yes / No	
Are you of Torres Strait Islander Origin? Yes / No	
Are you both Aboriginal and Torres Strait Islander Origin?  Yes / No	

Medicare Card Number:		
Ref.  		
Expiry:		
Centrelink HCC Number:		Expiry:		
Centrelink Pension Number:		Expiry:		
DVA Card Number:		Expiry:		

Next of Kin Name:		
Phone Number:		
Relationship to Patient				
Emergency Contact Name:		Phone Number:		
Name of last doctor/surgery?				

Do you wish to receive SMS appointment and clinical reminders?   Yes / No		
How do you wish to receive prescriptions? 	Paper	Email token	SMS token	
How did you hear about us? Please tick all that apply. 		

     Word of mouth		

     Internet Search	

     Emergency Dept.	

     Newspaper	

     Chemist	

     Radio	

     Television	

     Referral	

     Corporate Medical	

     Signage	

     Referral from other surgery	
Have you read and understood the privacy policy and fee structure?  Yes / No	
Please note that we are a private billing practice.	
I understand that the above medical practice complies with the Privacy Act (1988) and as part of their Privacy Policy, they are committed to protecting the privacy of individuals and their personal information. The purpose for collecting my personal information is to provide quality medical and health related services and associated account keeping.  I understand that I have the right to request access to my information except where access would be denied and that the above medical practice makes every effort to manage my information in accordance with the National Privacy Principles and keep my records accurate and up to date. I understand that I may withdraw my consent for the above Medical Practice to use and disclose my personal information (except when legal obligations must be met).
My signature below indicates that I have read the above and consent to: (cross out what is not relevant)
-	The above Medical Practice collecting, using, storing and disposing of my personal information
-	The release of relevant information by the above Medical Practice to other health professionals (e.g. specialist, pathologist)
-	Inclusion in a recall register to be advised of follow up visits, medical updates and health information
-	Contact by the practice via electronic means (including but not limited to mobile phone, sms, email and internet)
-	The release of relevant personal information to my employer, their authorised representatives and their insurer in the case or a work related consultation or service
-	I understand that all accounts must be paid at the time of the consultation.	

Signature:		
Date:		

NEW PATIENT QUESTIONNAIRE
This brief questionnaire will help the doctor assess you at your first appointment.
Please complete while you are waiting for your doctor.	

Patient Name:		

Date of Birth:		
MEDICAL HISTORY	
Do you have any pre-existing conditions you think your doctor may need to know about? E.g. asthma, diabetes, epilepsy, cancer, heart disease, high blood pressure, and so on. 	

	
FAMILY HISTORY	
Are there any health problems that run in your family that you think the doctor should know about? E.g. cancer of any type, heart diseases, and so on.	
Father	Mother	

MEDICATION	
Are you taking any medication?	

     Yes         No	
If yes, please list below:	

ALLERGIES	
Tick more than one box if applies:	

      I have no known allergies	

      I get hay fever	

      I am allergic to:	

      I carry adrenaline (Epipen)	

      Severity: Mild / Moderate / Severe	

      Type of reaction
Ie Wheeze/Rash		
SMOKING	

Do you smoke?          Yes         No	If yes, how many per day?		
If yes, how old were you when you started?	
If you’re an ex-smoker, how older were you when you gave up permanently?	
Are you interested in quitting smoking?		
ALCOHOL	

Do you drink alcohol?          Yes         No	If yes, how many units per week?		
VACCINATION/IMMUNISATION	
When was your last Tetanus injection?	
For children, are immunisations up to date?	

      Yes          No	
MEDICAL SCREENING – If applicable, when were the following tests carried out?	
For Women?	Pap Smear	Mammogram	Cholesterol & Glucose Check	
For Men?	 	Prostate Check	Cholesterol & Glucose Check	

I accept and acknowledge that I have answered the above questions correctly.	

Patient Signature:		

Date: