New Patient Enrollment Form

PATIENT INFORMATION
Title
SURNAME (as per Medicare card)
FIRST NAME
PREFERRED NAME
DATE OF BIRTH

DayMonthYear
ADDRESS

Street Address

Street Address Line 2

SurburbState

Postcode
TELEPHONE - HOME
TELEPHONE - WORK
TELEPHONE - MOBILE
Email
example@example.com
EMERGENCY CONTACT NAME/RELATIONSHIP
EMERGENCY CONTACT NUMBER
MEDICARE No.
Number against your name
Expiry
MM/YYYY
HEALTH FUND
MEMBER No:
HEALTH QUESTIONAIRE
DATE COMPLETED

DayMonthYear
COUNTRY OF BIRTH
OCCUPATION
F/T OR P/T
OBSTETRIC HISTORY
Have you ever delivered a vaginally?
If yes, how many?
Have you ever had a caesarean section?
If yes, how many?
Have you ever had a miscarriage?
If yes, how many?
Have you ever had an ectopic pregnancy?
If yes, how many?
Have you had an abortion?
If yes, how many?
Any other relevant obstetric history or complications:
SCREENING TEST
Last Pap Smear
DD/MM/YYYY
-
Last mammogram
DD/MM/YYYY
-
Last bone density
DD/MM/YYYY
-
If any of the above were abnormal please advise treatment and dates
GYNAECOLOGY HISTORY/SURGERIES
Do you have a gynaecological history?
If yes – Please list any Gynaecology history with dates:
Have you had any previous surgery if so please detail when and if any complications:
If yes - Please detail when and if any complications:
ANAESTHETICS
Have you had a general anaesthetic before?
Have you had a local anaesthetic before?
Have you had an epidural or spinal before?
Did you have any problems with any of the above?
If yes, please specify
ALLERGIES
Drug (e.g. Penicillin)
Food
Other
MEDICATIONS
Are you currently on any regular medications?
If yes – please provide name of drug/doseage
OTHER CURRENT INTAKE
Cigarettes
If yes, how many per week?
Alcohol
If yes, how many per week?
Recreational drugs
If yes, how many per week?
MEDICAL CONDITIONS
Please answer yes or no if you have ever had any of the below:
Heart Attack
Heart problems
Rheumatic Fever
High Blood Pressure
High Cholesterol
Stroke
Thyroid problems
Migraines
Anxiety
Depression
Gastric reflux
Ulcers (Gastric etc)
Irritable bowel
Back pain
Arthritis
Epilepsy/Fits
Asthma
Diabetes
Anaemia
Bleeding/Bruising
Deep Vein Thrombosis
Varicose Veins
Pulmonary Embolus
Recurrent Candida/Thrush
Chlamydia
Pelvic Inflammatory Disease
Herpes
Hep A, B, C, HIV Aids
Please list other medical conditions/concerns you would like Dr Chia to be aware of:
Relevant Family History

Please list any family members with significant medical history including cancer (e.g. Mother’s sister – alive – 40yo –breast, bowel or ovarian cancer)
Mother
Age
Health Problems
Father
Age
Health Problems
Any other relevant family history you want to note:
The information I have given is correct and complete to the best of my knowledge.
Signature of patient

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Date

DayMonthYear
- I understand that Dr Chia takes a full medical history that relates to my medical condition and management.
- I agree that relevant information may be obtained from other medical practitioners, such as GP’s and specialists, other health care providers, pathologist, hospital and Day Surgery Units as necessary.
- I agree that Dr Chia may discuss my medical history, diagnosis and management with my general practitioner and other relevant Medical Specialists in relation to my medical management.
- I understand that I may apply to access my health records.
- I understand that I am responsible for my account to be paid by the due date and any unpaid accounts that require follow up outside of the practice, will acquire a 30% Collection fee in addition to any legal costs incurred.
Patients Signature

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Date

DayMonthYear
Witness Signature

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Date

DayMonthYear
Witness Name
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PATIENT INFORMATION

HEALTH QUESTIONAIRE

OBSTETRIC HISTORY

SCREENING TEST

GYNAECOLOGY HISTORY/SURGERIES

ANAESTHETICS

ALLERGIES

MEDICATIONS

OTHER CURRENT INTAKE

MEDICAL CONDITIONS