First Name *

Middle Name

Surname *

Address *

Suburb *

Postcode *

Sex *

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Female
Other

Sex Other

Transgender
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Date of Birth *

Home Phone *

Mobile Phone

Email *

Medicare Number *

Ref Number *

Expiry Date *

Pension Card Health Card or Veterans Affairs

Pension Card Health Card or Veterans Affairs Expiry Date

Are you of or from Aboriginal or Torres Strait Islander Origin? *

Please state your family cultural or geographic origin *

Next of Kin *

Next of Kin Relationship *

Next of Kin Contact *

What is your occupation? *

Are you a smoker? *

No
Yes
Ex-smoker

If yes, how many cigarettes a day?

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Do you drink alcohol? *

If yes, how many standard drinks a day?

Do you have any medical problems? *

Do you have a history of any mental illness? *

Have you had any surgery? *

Have you undergone a colonoscopy gastroscopy and or cystoscopy? *

Do you have any allergies? including food drugs lotions latex etc *

What medications are you taking? *

Are there medical problems in your family? *

Ladies - When was your last pap smear and was it normal?

Ladies - When was your last mammogram and was it normal?

Gentlemen - When was your last prostate check?

Finally, have you seen any other GPs recently? *

Do you regularly see other specialists? *

Security, What is 1 + 4? *

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By submitting this form I acknowledge that I have had full opportunity to read and consider the contents of this form and your of Practice Policies. I understand that, by submitting this form, I am giving my consent to your use of my health information to carry out treatment, payment and healthcare management.

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