Patient Registration

Title

First Name

Last Name

Date of Birth

Middle initial

Preferred name

CONTACT DETAILS

Street address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Postal address (if different to above)

Mobile phone

Work phone

Home phone

Email

Medicare number

Medicare expiry

Reference number

DVA Gold / White

Pension / HCC

DVA Expiry

Pension/HCC expiry

NEXT OF KIN

Full name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Relationship to patient

Consent to contact if we are unable to contact you?

Yes
No

EMERGENCY CONTACT (if different to above)

Full name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Relationship to patient

Consent to contact if we are unable to contact you?

Yes
No

CULTURAL BACKGROUND

Australia is a multicultural society. To tailor appropriate care, encourage understanding and appreciation between people from different nationalities and backgrounds - do you identify as someone from a culturally and/or linguistically diverse background?

If yes please elaborate:

Are you of Aboriginal or Torres Strait Islander Origin?

Yes - Aboriginal
Yes - Torres Straight Islander
Yes - Aboriginal & Torres Strait Islander
No

Do you have any ALLERGIES or are you sensitive to drugs or dressings

Yes - please list below
No

Please list any allergies:

Current medications: (including over the counter vitamins and minerals)

Do you intend to have ongoing medical care provided by Terang Medical Clinic?

Yes - please complete PART B
No

If yes, please choose next and scroll up to complete PART B. If no, please skip to PART C.

REMINDER SYSTEMS

Our practice provides all patients with preventative care and early case detection reminders eg. immunisations, annual health checks, skin checks and pap smears.

Do you wish to have relevant health reminders sent to you?

Yes - via mail
Yes - via SMS to mobile
No

FAMILY HEALTH HISTORY

If yes to any of the above, please provide details

IMMUNISATIONS

Tetanus booster

Date

Hepatitis A

Date

Hepatitis B

Date

Influenza

Date

Pneumococcal

Date

Polio

Date

If completing for a child, are their immunisations up to date?

Yes
No

SOCIAL HISTORY

Tobacco use:

Yes - I currently smoke
Yes - but have ceased smoking
No

If yes, please provide details amount per day/week or when you ceased smoking

Alcohol consumption:

Yes - daily
Yes - weekly
Yes - on occasion
No

If yes, please provide details on amount consumed per day/week/month

Drug use:

Yes - daily
Yes - weekly
Yes - on occasion
No

If yes, please provide details on type and frequency

Your height (cms)

Your waist measurement (cms)

Your weight (kgs)

Blood pressure

When was the last time your blood pressure was taken?

Please provide any other relevant information:

Confirmation of information *

I agree to the below statement

I confirm that all information provided is true and correct and that there is no other information that I am aware of that would influence the medical treatment and/or advice to be provided.

We are committed to providing our patients with the best care. To do this it is essential that your health record is kept up to date and accurate.

CONTACT DETAILS

NEXT OF KIN

EMERGENCY CONTACT (if different to above)

CULTURAL BACKGROUND

REMINDER SYSTEMS

YOUR HEALTH HISTORY

FAMILY HEALTH HISTORY

IMMUNISATIONS

SOCIAL HISTORY