New Patient Registration Form

Surgery location * Required
Name * Required
Title First Surname
Date of Birth * Required
MM slash DD slash YYYY
Gender * Required
Ethnicity * Required
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone * Required
Work Phone * Required
Mobile * Required
Email * Required
Country of birth * * Required
Are you of Aboriginal or Torres Strait Islander origin? * Required
Language spoken
(if other than English)

Emergency Contact Name * Required
First Last
Address * Required
Street Address City State / Province / Region ZIP / Postal Code
Relationship to you * Required
Phone * Required

Next of Kin Name * Required
First Last
Address * Required
Street Address City State / Province / Region ZIP / Postal Code
Relationship to you * Required
Phone * Required

Name of last Doctor / Surgery * Required
Medical History * Required
Do you have any pre-existing conditions that you think the doctor may need to know about? Eg: asthma, diabetes, epilepsy, cancer, heart disease, high blood pressure, and so on
If yes, please list * Required
Family History * Required
Are there any health problem that run in your family that you think the doctor should know about? Eg: cancer of any type, heart disease, and so on
If yes, please list * Required
Medication * Required
Are you taking any medication?
If yes, please list * Required
Allergies * Required
Select all that apply
- I have no known allergies
- Hay-fever
- Eczema
- Asthma
- I carry adrenaline (eg: Epipen)
- Other
If other, please list * Required
Smoking * Required
Do you smoke?
If yes, how may a day? * Required
If yes, how old were you when you started? * Required
Are you interested in quitting smoking? * Required
How old were you when you gave up smoking permenantly? * Required
Alcohol * Required
Do you drink alcohol?
If yes, how many units per week? * Required
When was your last tetanus injection? * Required
Vaccination / Immunisation * Required
For Children, are immunisations up to date?
Medical Screening for Women
If applicable, when were the following tests carried out
Pap Smear Mammogram Cholesterol & Glucose check
Medical Screening for Men
If applicable, when were the following tests carried out
Prostate Check Cholesterol & Glucose check