Microsoft word - forms-_patient_registration[1].doc

PRIOR TO SEEING DR GRAZE – PLEASE COMPLETE THE FOLLOWING

((MR / MRS / MS / MISS / DR) SURNAME: ……………………………………………………………….
GIVEN NAMES: .……….
PREFERRED NAME…………………………………………………………………………………………….
If Child: Parent/Guardian Ful Name………………………………………………………………………….
ADDRESS : ………………………………………………………………………………………………………
…… ………………………………POST CODE .DATE OF BIRTH: ……./……./…….
TEL NO. (Home) ……………………. ………….(Work) ……………….……………………………………
(Mobile) ……….……………………….(Email)……………………………………………………. NAME OF REFERRING DOCTOR: ………………………………………….…… NAME OF USUAL GP (If different to above) ……………………………………… PRIVATE HEALTH FUND …………………………………………………………. Are you covered for Private Hospital? . YES/NO…. MEMBER NUMBER ………………………………. MEDICARE No: …………………………………. REF NO…………EXPIRY DATE ……………………. ARE YOU AN AGE PENSIONER? YES / NO - File No……………………………. YES / NO - Claim No…………………………. Work cover Insurer Details……………………………………………………………………………………. How did you hear about us?? GP / HOSPITAL OTHER ………………………………………………………… Privacy Policy - Your consent is required for this practice to disclose information to others involved
in your health care management, including treating doctors and specialists outside this practice, any
medical tests or reports that are relevant to your ongoing treatment.
Patient/Guardian……………………………………………………………Date…………………………….


PRIOR TO SEEING DR GRAZE – PLEASE COMPLETE THE FOLLOWING
PAST MEDICAL HISTORY:
It is important to list relevant current or past problems
1. Heart and Vascular System
3. Digestive System
4. Urinary System
5. DVT / Pulmonary Embolus
6. Specific ongoing joints, muscles or
bone conditions
7. Brain and Nervous system
8. Previous hospitalisation or
surgery
9. Are you Diabetic?
10.Are you a smoker… If so how many
cigarettes per day

Medications?
Is there a list of current medications on your referral?? If not please list.
………………………………………………………………………………………………………………………………

Family history of medical problems? …………………………………………………………………………………….
Allergies? (give details) ……………………………………………………………………………………………………
……………………………………………………………………………………………………………………………….
OCCUPATION …………………………………… ?? RIGHT OR LEFT HANDED………………AGE.……………
Drs Notes
Diagnosis/Plan

Source: http://gcorth.com.au/sites/default/files/files/FORMS-_Patient_Registration.pdf

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