New Patient Registration Form

Name*
Title First Surname
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender*
Ethnicity*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Work Phone*
Mobile*
Email*
Country of birth*
Are you of Aboriginal or Torres Strait Islander origin?*
Language spoken
(if other than English)

Name of last Doctor / Surgery*
Medical History*
Do you have any pre-existing conditions that you think the doctor may need to know about? Eg: asthma, diabetes, epilepsy, cancer, heart disease, high blood pressure, and so on
If yes, please list*
Family History*
Are there any health problem that run in your family that you think the doctor should know about? Eg: cancer of any type, heart disease, and so on
If yes, please list*
Medication*
Are you taking any medication?
If yes, please list*
Allergies*
Select all that apply
- I have no known allergies
- Hay-fever
- Eczema
- Asthma
- I carry adrenaline (eg: Epipen)
- Other
If other, please list*
Smoking*
Do you smoke?
If yes, how may a day?*
If yes, how old were you when you started?*
Are you interested in quitting smoking?*
How old were you when you gave up smoking permenantly?*
Alcohol*
Do you drink alcohol?
If yes, how many units per week?*
When was your last tetanus injection?*
Vaccination / Immunisation*
For Children, are immunisations up to date?
Medical Screening for Women
If applicable, when were the following tests carried out
Pap Smear Mammogram Cholesterol & Glucose check
Medical Screening for Men
If applicable, when were the following tests carried out
Prostate Check Cholesterol & Glucose check