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HEALTH SUMMARY
Title
Mr Ms Mrs Mast Miss Dr (please circle)
Given Names
Surname
Address:
Home:
Mobile:
Gender: Male / Female
Date of Birth:
Email:
Occupation: (incl. home duties/ student/ child)
Country of birth:
Aboriginal
Torres Strait Islander
Neither (please circle if applicable)
Emergency Contact:
Name:
Number:
Relationship to patient:
Medicare No.
_ _ _ _ _ _ _ _ _ _
Ref. _____
Expiry __ __/__ __ __ __
DVA No
_ _ _ _ _ _ _ _
WHITE / GOLD (please circle)
Expiry __ __/__ __ __ __
Health / Pensioners Card (please circle)
__ __ __ __ __ __ __ __ __ __ __ __ Expiry __ __/__ __ __ __
Private Health Insurance (company, type of cover, extras):
BASIC
INTERMEDIATE
TOP
(please circle)
Social/Family Structure
Who lives at home with you?
Are there any existing court orders on children 17 years
and under?
YES / NO (please circle)
Marital status:
No. of children:
No. of brothers or sisters you have:
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Previous General Practitioner:
Address:
Phone:
Last seen on:
Allergies (if any
):
Do you drink alcohol now?
YES / NO (please circle)
If so, how many days a week do you drink? 1–2 days 3-4 days 5-6 days Every day Less than Monthly
How many drinks per day
If not, have you ever been a drinker? (if so when):
Do you smoke?
YES / NO (please circle)
If so, how many do you smoke per day:
If not, have you ever been a smoker? (if so when):
Past Medical History:
Have you had any operations? Please list type & approximate date:
Do you have any of the following conditions / diseases (please tick all that apply) :
Asthma
Emphysema
Tuberculosis
Heart disease
Stroke
High blood pressure
High cholesterol
Eye condition
Coeliac disease
Blood clots
Hepatitis
Peptic ulcer
Arthritis
Gout
Osteoporosis
Dermatitis/Eczema
Psoriasis
Dementia
Migraines
Seizures or fits
Anxiety
Depression
Schizophrenia
Anaemia
Abnormal pap smear
Cancer of any type
Diabetes
Any other conditions:
Immunisations: Up to date with childhood immunisations: (where applicable)
YES / NO (please circle)
Travel vaccines received:
Current Medications
Prescriptions:
Over the counter :
Herbal :
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Activity
What form of activity do you do each week? eg. walking, golf, gardening. How many days per week do you do each?
Do you ever experience any of the following during or after exercise? Breathlessness Cough Wheeze
Chest pain Dizziness (please circle)
Family History
Do you have a family history (including parents/siblings/extended family) of any of the following: (circle all that apply)
High blood pressure High cholesterol Heart disease Stroke Cancer Eye condition Diabetes
Blood disorder
Asthma
Eczema
Any other conditions:
Women’s Health (as appropriate)
When was your last pap smear?
Was it:
Normal Abnormal Not sure (please circle)
When was your last mammogram?
Is there a family history of breast cancer? Mother Sister Other relative (please circle)
Are you pregnant currently? YES / NO (please circle)
Men’s Health (as appropriate)
When was the last time you had a prostate examination?
Never
Can’t Remember
_________Years ago
Reminder Systems:
Our practice provides our patients with preventive care and early case detection reminders:
e.g. immunisations, annual health checks, skin checks and pap smears.
I agree to have any relevant health reminders sent to me. I agree to receive SMS contact/reminders from the surgery.
Who completed this form?:
SELF / OTHER (please circle)
If other, name, phone no. and relationship to patient:
Signature: ________________________________ Date:____________________
