St George Oncology - Personal details and Medical History

Personal Details
First Name*
Middle Name
Last Name*
Date of Birth*

DayMonthYear
Country of birth*
Preferred language*
Do you require an interpreter?

YesNo
Home Phone Number
Mobile Phone Number*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email address:*
example@example.com
Next of kin*
Name and relationship to you
Next of kin phone number*
Insurance information
Medicare number*

Card numberReference number (next to name)
Medicare card expiry date*

MonthYear
Pension/Health Care Card/DVA number*
Or type NA
Private Health fund name*
Or type NA
Private Health fund number*
Or type NA
Referring Doctor - name and suburb*
Please include suburb and phone number if you have it
General practitioner - name and suburb*
Please include suburb and phone number if you have it
Please list any Specialists that you see regularly so that we can write to them an update of your visit.*
Medical history and Medications
It is important for us to plan the length of your appointment and what medical information and results are required in preparation. What type of appointment have you booked at St George Oncology Associates?*

First consultation with a Medical Oncologist or HaematologistSecond opinion with a new Medical Oncologist or HaematologistFollow up appointment
As you have indicated that you are attending for a second opinion with one of our doctors, the quality of the opinion you receive will be dependant on how much information you are able to provide. We request that you gather as much information as possible prior to the appointment.

Your appointment may be delayed if we do not receive all of the results in time.

Please upload the relevant documents below or email through to reception@stgeorgeoncology.com. Please call if you need help on 02 9553 9220.
Upload histopathology report

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The report that demonstrates that you have cancer Cancelof
Upload most recent blood result

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Upload most recent scan reports

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Upload any relevant doctors letters or other medical reports

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Please list below if you have any ongoing health problems. NOTE: we often do not receive your medical history from other doctors so it is important for you to complete this.*
Eg, high blood pressure, diabetes, heart disease, previous cancers
Please list any medications you currently take (including over-the-counter medications, vitamins and minerals). NOTE: the doctors often do NOT have access to your medications from other doctors.*
Do you have any allergies or are you sensitive to anything?*

NoYes
If yes, please indicate below:*
If not mentioned above, do you currently have, or have a history of:*

No health condionsHigh Blood PressureHigh cholesterolAsthma / Lung ProblemsType 1 DiabetesType 2 DiabetesMental Health IllnessHeart problemsPacemakerProsthetic heart valveBlood clots in leg or lungOther
Have you had any major operations?*
Are there any cancers that run in your family?*

Breast cancerBowel cancerOvarian cancerProstate cancerNo cancers in familyOther
Social History
Who lives with you at home?*

AloneSpouseSpouse & ChildrenOther
How many children do you have?*
If yes, what are your childrens ages?*
Are you currently working?*

NoYes - casuallyYes - part timeYes - full time
What is your occupation, or what was your occupation if retired?*
Do you smoke cigarettes?*

NoYesEx Smoker
If yes, how many per day?*
Ex smoker - how long ago did you quit?*
Do you drink alcohol?*

NoInfrequentlyRegularly
If yes, how many drinks do you consume per day/week/month?*
Thank you for completing this information, it will greatly assist with your appointment. We look forward to meeting you soon.
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Personal Details

Insurance information

Medical history and Medications

Social History