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Title:

Surname (required):

First & Middle Name(s) (required):

Preferred Name:

Country of Birth:

Date of Birth:

Age:

Sex:
Marital Status:

Occupation:

Street Address:

Postal Address (if different):

Suburb:

State:

Postcode:

Email:

Person responsible for account:

Person responsible for Account:

Person responsible contact details
Address:

Phone:

Email:

Guardian/ Next of kin (if applicable):

Guardian Phone:

REFERRAL AND PRACTITIONER DETAILS:

Referring Practitioner:

Address:

Phone:

General Medical Practitioner (GP):

Address:

Phone:

General Dentist:

Address:

Phone:

MEDICARE & HEALTH INSURANCE DETAILS:

Medicare Details:

Medicare Card (Card No 10 Digits on card):

Expiry Date MM/YY:

Ref No. (digit next to your name):

Private Health Insurance:

Fund Name:

Member No:

Dental Extras Fund:
NoYes
Hospital Cover:
NoYes

Veteran Affairs:

Card No:

Expiry Date:

TAC/Workcover

Insurer:

Claim No:

Claims Contact:


MEDICAL SUMMARY

HAVE YOU HAD OR CURRENTLY HAVE:
Rheumatic feverNoYes
DiabetesNoYes
Heart problemsNoYes
Heart murmurNoYes
EpilepsyNoYes
Kidney diseaseNoYes
HepatitisNoYes
AsthmaNoYes
High blood pressureNoYes
OsteoporosisNoYes
Stomach reflux/ulcerNoYes
Excessive bleedingNoYes

 

DO YOU HAVE ANY ALLERGIES TO:
PenicillinNoYes
AspirinNoYes
LatexNoYes
Elastoplast or tapesNoYes

 

Any other medication allergies?: NoYes If yes, please provide details in box below (180 or less characters):

Any food allergies?: NoYes

Any other allergies?: NoYes If yes, please provide details in box below (180 or less characters):

Have you smoked cigarettes/cigars within the last 4 weeks?: NoYes
Are there any other "risk factors" you need to discuss in your consultation? (180 or less characters):

Have you EVER taken any medications for osteoporosis or bone conditions/lesions? (eg. Fosamax, Actonel, Zometa, Pamisol, Didronel, Didrocal, or Aredia): NoYes
Please list ALL medications you are currently taking (including vitamin supplements and inhalers) (180 or less characters):

Please list ALL previous operations (180 or less characters):

Describe any serious illness you have previously suffered (180 or less characters):

General Anaesthetics

Have you had problems with general anaesthetics or a family history of malignant hyperthermia? (180 or less characters):

Females

Are you pregnant?: NoYes
Are you taking the oral contraceptive pill?: NoYes

PRIVACY STATEMENT

Our practice respects your right to privacy and complies with the legislation relating to the collection, storage, use and disclosure of health information. For more information please ask for the Privacy Statement handout.

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