EdgecliffWoy WoyMirandaKiamaHoxton Park

Medical History Form

Location

Which practice would you like to register with? EdgecliffWoy WoyMirandaKiama
Have you ever been treated here before? YesNo

Patient's Details

Patient's Name:
Title: MrMrsMissDr
Address:
Suburb:
State:
Postcode:
Sex: MaleFemale
Date of Birth (dd/mm/yyyy):
Age:
Phone (Home):
Phone (work):
Mobile:
Email:
Patient's Occupation:
Are you in a health fund? YesNo
Fund Name:
Card Number:
Do you hold a Veterans Affairs Gold Card? YesNo
Medicare card Number:

We are grateful that our practice grows by referral. Who should we thank for referring you?

General health Questions

1. How would you describe your general health?
ExcellentGoodFairPoor

2. Are you under the care of a doctor for any medical conditions?
YesNo

If yes, please explain

3. Name and address of family doctor

4. Are you wearing a pacemaker or heart valve prosthesis or do you have a joint replacement or any other medical implant?
YesNo

If yes, please explain

5. Have you ever had abnormal bleeding associated with previous extractions, surgery or trauma?
YesNo

If yes, please explain

6. Are you taking any kind of medications (prescribed or non-prescribed) or drugs at this time?
YesNo

If yes, please explain

7. Have you been diagnosed as having HIV, AIDS (Acquired Immune Deficiency) or ARC (Aids Related Complex)?
YesNo

8. Are you pregnant?
N/ANoYes How Many Months:

9. Are you allergic or have had an unusual reaction to any of the following (Please select all relevant).

PenicillinCodeineSedatives AspirinSteroidsIbuprofen Nitrous OxideErythromycinLatex! Rubber Sulpha DrugsValiumFlagyl

If Other, Please State:

10. Do you have a history of any of the following disorders? (please select)

Lung DiseaseSinus TroubleHeart TroubleHay FeverKidney TroubleTuberculosisHepatitis AHepatitis BHepatitis C Blood DisordersThyroid TroubleHeart AttackHeart MurmurConvulsionsEpilepsyDepressionMigraineSleep Apnoea AnaemiaAsthmaHerpesArthritisDiabetesGlaucomaAnginaStrokePalpitations Stomach Ulcer/RefluxFainting SpellsChronic Bronchitis/CoughShortness of BreathRheumatic FeverCancer TreatmentPsychiatric TreatmentHigh Blood PressureHives or Skin Rash

11. Do you currently receive, or have you ever received, occasional injections by a doctor or specialist for Osteoporosis?
YesNo

12. Have you ever taken any of the following medications (Please select)

FosamaxActonelZometa DidrocalPamisolAlendro DidronelArediaBoniva SkelidBonefosAclasta

13. Is there anything else about your health we should know?

Please enter the code displayed: captcha

I agree the above information is to the best of my knowledge are true and correct.

Please select Yes for Acceptance: YesNo

Today's date:

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