Title
Mr
Mrs
Ms
Miss
Dr
Prof
Other
Date of Birth
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Mobile OR Home Phone
*
Email Address
*
Next of Kin
Name, Contact Number and Relationship to Patient
Medicare Number
Health Insurance Company
Member Number
Type of Cover
We can admit you to a private hospital only if you have Hospital Cover
Level of Cover
Check with your insurance company if unknown
DVA Number
Is this your usual GP?
If no, please provide your regular GP's details
Name & Practice Details
Other specialists interested in your care
Name & Practice Details
What is the main symptom or problem you need help with?
List your current medications, including over the counter and non-prescribed tablets:
List any active or previous medical conditions:
Have you every been admitted to hospital?
If so, what for?
Have you every had any previous surgery?
Do you take Warfarin, Isocover, Plavix, Pradaxa, Eliquis or Xarelto or other blood thinner?
Do you have any allergies?
Do you live alone?
This is important after discharge from hospital
If not, who is at home with you?
Do you have children?
Do you smoke?
Are you an ex-smoker?
Do you drink more than two alcoholic drinks per day?
Are there any illnesses that run in the family?
If yes, please specify
Have you ever had a colonoscopy?
Have you ever participated in the national bowel cancer screening program?
