Patient Information Registration "*" indicates required fields 1Step 1 - Patient Information2Step 2 - Patient Questionaire3Step 3 - Authorisation Preferred DoctorPreferred Doctor **Please Select ...Professor Richard HarveyDr. Julia CrawfordDr. Sean FlanaganDr. Cara MorrisDr. Marina CavadaDr Jessica TattersallPersonal InformationTitle* First Name* Surname* Patient Type* Adult Child Known as DOB* DD slash MM slash YYYY Home PhoneMobile*Work PhoneEmail* Address* Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweCountryPostal Address (If different from aside)Emergency ContactName* Relationship to you* Contact Number*GP & ReferrerGP: Name & Address* Referring Doctor (If different from above) Medicare & Healthcare FundDo you have a Medicare Card?* Yes No Medicare no.* Reference on card* Do you have a Health Fund?* Yes No Health Fund* Membership Number* Have you been admitted to hospital in the last twelve months?* Yes No Should we contribute your medical information to www.MyHealthRecord.gov.au?* Yes No New Patient Paediatric QuestionnaireWhat problem/s is your child experiencing?*New Patient QuestionnaireWhat problem/s brought you here?*History of present illnessPlease describe the location of your problem:*Please describe the location of your child’s problem:*How long have the symptoms been present (months/years)* Do you have any drug/medication allergies?* Yes No Does your child have any drug/medication allergies?* Yes No What are you allergies?What are your child's allergies?Have you had any MEDICAL problems (diabetes, cancer, infections, etc) in the past?* Yes No Please list any MEDICAL problems including the dates, if possible:*Has your child had any MEDICAL problems (diabetes, cancer, infections, etc) in the past?* Yes No Please list any MEDICAL problems your child has had including the dates, if possible:*Have you had any SURGERIES in the past?* Yes No Please list any SURGERIES that you have had in the past, including dates, if possible:*Has your child had any SURGERIES in the past?* Yes No please list any SURGERIES that your child has had in the past, including dates, if possible:*Do you have asthma?* Yes No Does your child have asthma?* Yes No Do you use Inhalers?* Regular use Intermittent only I don't use Inhalers usage?* Regular use Intermittent only I don't use Do any diseases or cancers run in your family?* Yes No Please list any diseases or cancers that run in your family:*Current MedicationsAre you currently taking any medication? Yes No Does your child currently taking any medication? Yes No MedicationsNameDoseFrequency Add RemoveChild's MedicationsNameDoseFrequency Add RemoveAdditional Specialists (Audiologist, Physiotherapist, Endocrinologist, etc)Additional Specialists (Pediatrician, Audiologist, Speech therapist, Respiratory, Endocrinologist, etc)Additional Specialist: None Immunisation trackAre immunisations up to date?* Yes No Social HistoryOccupation Does your workplace require:Noise/hearing precautions?* Yes No Mask/breathing protection?* Yes No Heavy vocal/voice use?* Yes No Use of smell?* Yes No Have you ever smoked?* Yes No Smoked within 12months?* Yes No How many (cigarettes)/day?* The age you started smoking(y/o)* and quit(y/o)* Do you drink alcohol?* Yes No How many (drinks) /day?* How many alcohol free days/week?* Do you use recreational drugs?* Yes No What kind?* Any intranasal use?* Yes No School year* Does your child snore?* Yes No Does your child have speech/language delays?* Yes No Have behavioral issues?* Yes No Guardian/Parent Name* PERMISSION TO COLLECT AND STORE INFORMATION We need to collect and store some information about you: To help us provide good and safe treatment and to provide Government bodies with information to which they are legally entitled. These records will contain information including, but not limited to, your name, address, date of birth, Medicare number, referring doctor’s details and clinical imaging and records. Your medical information is also used, in an unidentifiable way, for auditing, research and education purposes. We undertake only to collect information which is appropriate to your total care and to only use the information for its intended purpose. Your medical records are stored securely and can only be accessed by authorised staff. We are required to keep your records for up to seven years following your last consultation. If necessary, for the continuity of your medical care, this information may be shared with other health practitioners involved in your treatment. In certain circumstances there may be a legal obligation to disclose clinical information, for example to Government bodies. A full copy of our privacy policy is available on request. Date* DD slash MM slash YYYY Signature*Attach your referral form or any files you want to share here. File types accepted are PDF, PNG, JPG. Upload file size limit is 4mbFile UploadMax. file size: 32 MB.