New Patient Medical History FormOnly fill out this form if you have been instructed to by our staff. Name * First Name Last Name Email * Phone (###) ### #### Date of Birth * Postal Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Preferred Contact Method Phone Email Post Birth Gender This is only for testing purposes Female Male Medicare Card Number Medicare Card Expiry Next of Kin - Name Relationship to Next of Kin Contact Number Emergency Contact If different from next of kin Do you have a primary carer? Yes No If Yes - please provide contact details Ethnicity Are you Aboriginal or Torres Strait Islander? Aboriginal Torres Strait Islander Both Preferred Language Interpreter required? Yes No Please provide your GP details Advanced Health Directive Yes No Health History Medical History Surgical History Allergies and/or drug intolerances Current Medications Including over the counter remedies eg. Vitamins Pharmacy Details Lifestyle Smoking History I am a Lifelong non smoker Previous smoker Current smoker Alcohol Intake Please provide number of drinks per day/ per week Have you ever used illicit drugs? Yes No Social History What is or was your occupation? Do you live with? alone\ spouse \ partner\family What type of house do you live in? low set\ high set\unit\ caravan\ other How many stairs do you have to enter your property? Are you a primary carer for somebody else? Yes No Do you receive assistance in your home? yes/no, if yes from whom What assistance do you receive? Do you use mobility aids? yes\ no, if yes please state type aid Approximately how far can you walk? (using aid if required) Please sign in the section below if you consent to assessment and treatment and for me to contact your GP, Pharmacist and care agency, if required, for further information to assist in your assessment. Name Signature Date MM DD YYYY Thank you!
