New Patient Information Form

We are committed to providing our patients with the best care. To do this, it is essential that your health record contains complete and accurate information. Please assist us by completing this form:

Contact Information
Emergency Contact
Next of Kin
Healthcare Identifiers
  • Dept of Veteran Affairs card colour

Cultural Identity
  • To assist with health initiatives, do you identify as Aboriginal and/or Torres Strait Islander?

  • As Australia is a genuinely multicultural society, and to tailor appropriate health care, encourage understanding and appreciation between people from different nationalities and cultures – do you identify as someone from a culturally and/or linguistically diverse background?

  • Do you require an interpreter service?

Your Health Information
  • Allergy Information – Do you have any allergies or are you sensitive to drugs or dressings?

  • Current Medications – Please list all of your current medications, including complementary and over the counter medicines (eg homeopathic medicines, vitamins and minerals etc)

  • Medical History – Do you have or have you had a history of the following?

Lifestyle Risk Factors
  • Are you a smoker?

  • Do you drink alcohol?

  • Do you use recreational drugs?

Family Health History Information
  • Have any members of your family been affected by any of the following medical conditions?

  • Please list any recent immunisations you have had:

  • If completing this form for a child, are their immunisations up to date?