NEW PATIENT FORM
Welcome to our practice. Please fill this form out to help us better serve you.
1. Health Status
COVID-19 Risk Assessment
1. Health Status
COVID-19 Risk Assessment
1. Do you have a confirmed diagnosis of COVID-19?
Yes
No
2. Have you, or anyone living with you had contact with someone with a confirmed or suspected diagnosis of COVID-19?
Yes
No
3. Have you, or anyone living with you returned from overseas in the last 14 days?
Yes
No
4. Do you, or anyone living with you have the following symptoms (Please tick all symptons that apply);
Sore throat
Cough
Shortness of breath
High Temperature (38°C)
Runny nose, sneezing, post-nasal drip
Medical Health Assessment
Please tick YES or NO beside each medical condition AND write down the drugs taken next to the condition.
1. Heart murmur
Yes
No
Medication associated to your condition (if applicable)
2. Heart attack
No
Yes
If yes please tell us when it happened
Medication associated to your condition (if applicable)
3. Rheumatic fever
No
Yes
Medication associated to your condition (if applicable)
4. Open heart surgery
No
Yes
When and medication associated to your condition (if applicable)
5. High blood pressure
No
Yes
Medication associated to your condition (if applicable)
6. Stroke
No
Yes
Medication associated to your condition (if applicable)
7. Asthma
No
Yes
Medication associated to your condition (if applicable)
8. Chest & lung disease
No
Yes
Medication associated to your condition (if applicable)
9. Sinus/hay fever
No
Yes
Medication associated to your condition (if applicable)
10. Epilepsy
No
Yes
Medication associated to your condition (if applicable)
11. Diabetes
No
Yes
Medication associated to your condition (if applicable)
12. Kidney problems
No
Yes
Medication associated to your condition (if applicable)
13. Gastric problems
No
Yes
Medication associated to your condition (if applicable)
14. Depressive illness
No
Yes
Medication associated to your condition (if applicable)
15. Radiotherapy/Chemotherapy
No
Yes
Medication associated to your condition (if applicable)
16. Smoker
No
Yes
Medication associated to your condition (if applicable)
17. Artificial/prosthetic joint
No
Yes
If yes, please state when and what prothesis was placed:
18. Allergies
No
Yes
If yes, please state what allergies:
19. Are you a pregnant female?
No
Yes
If yes, please state how many weeks:
20. Any other medical conditions and medication intake?
No
Yes
If yes, please list all:
2. YOUR DETAILS
Name
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Prefix
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Date of Birth
-
Day
-
Month
Year
Date
Name of your GP
First Name
Last Name
Name of your Dentist
First Name
Last Name
Consent: I CONFIRM THAT THE INFORMATION ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Signed by
Patient
Parent
Guardian
Sign here:
Date
-
Day
-
Month
Year
Date
Submit
Should be Empty: