Patient Information Registration

"*" indicates required fields

1Step 1 - Patient Information

2Step 2 - Patient Questionaire

3Step 3 - Authorisation

Preferred Doctor

Preferred Doctor **

Personal Information

Title*

First Name*

Surname*

Patient Type*

Adult

Child

Known as

DOB*

DD slash MM slash YYYY

Home Phone

Mobile*

Work Phone

Email*

Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Postal Address (If different from aside)

Emergency Contact

Name*

Relationship to you*

Contact Number*

GP & Referrer

GP: Name & Address*

Referring Doctor (If different from above)

Medicare & Healthcare Fund

Do you have a Medicare Card?*

Yes

Medicare no.*

Reference on card*

Do you have a Health Fund?*

Yes

Health Fund*

Membership Number*

Have you been admitted to hospital in the last twelve months?*

Yes

Should we contribute your medical information to www.MyHealthRecord.gov.au?*

Yes

New Patient Paediatric Questionnaire

What problem/s is your child experiencing?*

New Patient Questionnaire

What problem/s brought you here?*

History of present illness

Please 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

Does your child have any drug/medication allergies?*

Yes

What are you allergies?

What are your child's allergies?

Have you had any MEDICAL problems (diabetes, cancer, infections, etc) in the past?*

Yes

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

Please list any MEDICAL problems your child has had including the dates, if possible:*

Have you had any SURGERIES in the past?*

Yes

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

please list any SURGERIES that your child has had in the past, including dates, if possible:*

Do you have asthma?*

Yes

Does your child have asthma?*

Yes

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

Please list any diseases or cancers that run in your family:*

Current Medications

Are you currently taking any medication?

Yes

Does your child currently taking any medication?

Yes

Medications

Name

Dose

Frequency

Child's Medications

Name

Dose

Frequency

Additional Specialists (Audiologist, Physiotherapist, Endocrinologist, etc)

Additional Specialists (Pediatrician, Audiologist, Speech therapist, Respiratory, Endocrinologist, etc)

Additional Specialist:

None

Immunisation track

Are immunisations up to date?*

Yes

Social History

Occupation

Does your workplace require:

Noise/hearing precautions?*

Yes

Mask/breathing protection?*

Yes

Heavy vocal/voice use?*

Yes

Use of smell?*

Yes

Have you ever smoked?*

Yes

Smoked within 12months?*

Yes

How many (cigarettes)/day?*

The age you started smoking(y/o)*

and quit(y/o)*

Do you drink alcohol?*

Yes

How many (drinks) /day?*

How many alcohol free days/week?*

Do you use recreational drugs?*

Yes

What kind?*

Any intranasal use?*

Yes

School year*

Does your child snore?*

Yes

Does your child have speech/language delays?*

Yes

Have behavioral issues?*

Yes

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*

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