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New Patient Form

    Patient Details

    Mr.Mrs.MissMs
    Gender

    MaleFemalePrefer not to Disclose
    Marital Status
    MarriedSingleDe factoWidowedDivorcedSeparated
    Surname
    Given Name
    Middle Name
    Preferred Name
    Date of Birth
    To assist with health initiatives – are you Aboriginal and/or Torres Strait Islander?
    As Australia is a genuinely multicultural society, and to tailor appropriate care, encourage understanding & appreciation between people from different nationalities & cultures - do you identify as someone from a culturally and /or linguistic diverse background?

    No AustralianYes Ethnicity

    Address
    Suburb
    Postcode
    Home Phone
    Work Phone
    Mobile
    Email
    Occupation
    Medicare Number
    Reference Number
    Expiry Date
    Card Name
    Card Number
    Expiry Date
    Welcome to Clermont Country Practice. Please take the time to fill in as much detail as possible. This will assist our team to provide the best possible care for you and your family.
    Next Of Kin
    Name:
    Phone (Home):
    Phone (Work):
    Relationship:
    Emergency Contact (If different from NOK)
    Name:
    Phone (Home):
    Phone (Work):
    Relationship:
    I consent to receive communication from Clermont Country Practice via SMS as per the contact numbers I have provided on this form, this may include third party communications through our Best Practice software or our appointment reminder system - Automed.
    YesNo
    If no, please see reception for alternative arrangement of communication

    Medical History

    Do you have any allergies?
    NoYes

    If yes, please list below.



    Do you take medication?
    NoYes

    If yes, please list below.



    Do you smoke?
    YesNoEx Smoker
    If Ex Smoker
    Year you started?
    Year you stopped?


    Do you drink alcohol?
    YesNo
    Year you started?


    Family History

    High blood pressure:
    NoYes
    Heart Disease:
    NoYes
    Stroke:
    NoYes
    Cancer:
    NoYes
    Depression or anxiety:
    NoYes
    Diabetes:
    NoYes
    Glaucoma:
    NoYes
    Dementia:
    NoYes
    Osteoporosis:
    NoYes
    Clotting or bleeding disorders:
    NoYes
    If yes, please provide details (mother or father)
    Mother:
    AliveDeceased
    Father:
    AliveDeceased

    Personal History

    Heart disease (heart attack, angina, stents, abnormal heart beat)
    NoYes
    High Blood Pressure
    NoYes
    Diabetes or raised blood sugar levels
    NoYes
    Blood clots in legs or lungs
    NoYes
    Depression and/or anxiety
    NoYes
    Asthma, COPD, or other lung disorders
    NoYes
    Bleeding or clotting disorder
    NoYes
    High cholesterol
    NoYes
    Stroke or brain haemorrhage
    NoYes
    Stomach ulcers, bowel problems, or other abdominal disorder
    NoYes
    Eczema, psoriasis, dermatitis, or other skin disorders
    NoYes
    Epilepsy, fits, convulsions or blackouts
    NoYes
    Migraines
    NoYes
    Back or spinal problems
    NoYes
    Any cancer/tumor, including skin cancer
    NoYes
    Osteo – Rheumatoid arthritis or other joint condition
    NoYes
    Surgical history/operations
    NoYes
    Others
    NoYes

    Additional Information

    Previous Medical Practice

    Previous Doctor:

    Clinic Name:

    Clinic Address:

    Suburb:

    Postcode:

    Contact Number:

    Fax:

    Patient Details

    Surname:

    First Name:

    Date of Birth

    Address:

    Suburb:

    Postcode:

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