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Confidential Patient Registration

Thank you for spending a few minutes filling in this form below.

PENSION HCC SNP CLUB NO
Card Exp Date

Account/Insurance Details
Medicare Number		Medicare Expiry Date
Your nbr on card
Do you have Private Health Insurance? (Hospital cover)	Yes No
Health Fund Name		Membership No

Please tick if you don't want any correspondence to be sent to your referring doctor and/or G.P
GP Name		Referring Doctor
GP Address (if different to referring doctor)		Any other medical practitioners: (please provide address details also)


Third Party Claim: Please select a bill payer if you are not responsible for your account
Veterans’ Affairs	NX/QX No		Card colour
Workcover	Claim No

Whom may we thank for referring you to our practice?
Name of the person
If not a direct referral, how you heard about us:
Other

Medical history/conditions		Details
Any allergies to medicines, tapes, antiseptics, food or Latex	Yes No
Heart murmurs or Heart conditions	Yes No
Blood pressure (high or low)	Yes No
Excessive bleeding	Yes No
Blood clots in the legs or lungs	Yes No
Hepatitis or liver disease	Yes No
Lung condition (shortness of breath, persistent cough, wheeze, asthma, TB, pneumonia)	Yes No
Diabetes – what type	Yes No
Stroke / epilepsy / fits	Yes No
Past history of cancer	Yes No
Kidney disease	Yes No
Psychiatric condition / history	Yes No
Previous operations	Yes No
Any history or family history of problems associated with anaesthetic	Yes No
Blood transfusion	Yes No
Any tests or investigations in the last 6 months	Yes No
Anaemia	Yes No
Do you smoke (if yes, how many per day)	Yes No
Could you be pregnant	Yes No
Do you have any reason to believe that you may have been exposed to the virus causing AIDS	Yes No
Have you used intravenous drugs	Yes No
Have you taken any blood thinning medications in the last week (e.g. Aspirin or Warfarin)	Yes No
Any other conditions you feel we should be aware of	Yes No
I take the following vitamins and supplements
My current medications are