Patient Registration Form 2/2 - Dr Malcom Linsell

General Medical History
Have you ever had any serious illness or operations?

YesNo
If answered 'Yes' to the above question, please state the serious illness(s) and/or operations.
Are you taking any medication now?

YesNo
If answered 'Yes' to the above question, please state which medication(s) you are currently taking.
Do you smoke?*

YesNo
Do you take recreational drugs?*

YesNo
Please check the box if you have ever had or been treated for:

Heart Disease or ConditionRheumatic Fever or Heart Murmur‎Abnormal Blood Pressure‎Stroke‎Epilepsy or Seizures‎Diabetes‎Lung Disease or Tuberculosis‎Asthma‎Bleeding Disorders‎Anemia‎Arthritis‎Glaucoma‎Kidney/Bladder Problems‎Ulcers or Intestinal Conditions‎
In the last 2 years, have you ever been treated with cortisone, steroids, or blood thinners?*

YesNo
Are you allergic to:

Penicillin‎Codeine‎Local Injected Anesthetics‎Other
Are you subject to fainting spells?*

YesNo
Are you pregnant?*

YesNo
Is there anything else concerning your health that we should know about?
CONSENT TO COLLECT PATIENT INFORMATION
This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and medical history so that we may properly assess, diagnose, treat, and be proactive in your health care needs. We will use this information you provide in the following ways:
1. Administrative purposes in running our medical practice.
2. Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
3. Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice as advised by you.
I understand the reasons why my information must be collected.‎I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me.‎I understand that if my information is to be used for any purpose other than the above, my consent will be sought.‎I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure of which I may notify this practice.‎
Patient Signature*

Clear
Patient Name*

First NameLast Name
Date*

MonthDayYear
Should be Empty:

General Medical History

CONSENT TO COLLECT PATIENT INFORMATION