Patient InformationProviding care for you and your family New Patient Information Form 1 Patient Details2 Medical History3 Consent Please tell us how you heard about us*GoogleFamily/FriendsOnline Yellow PagesFacebookOtherPlease tell us how you heard about usName Mr.Mrs.MissMs.Mast.Dr. Title First Middle Last DOB Date Format: DD slash MM slash YYYY SexFemaleMaleMarital StatusSingleMarriedDe factoSeparatedDivorcedWidowedNationalityOccupationMobile NumberWork NumberHome numberEmail address Address Street Address Suburb State Postcode Medicare NumberExpiry Date Format: DD slash MM slash YYYY Number to left of your namePension/HCCExpiry Date Format: DD slash MM slash YYYY DVA Gold cardDVA White CardExpiry Date Format: DD slash MM slash YYYY Private Health Insurance FundMembership NumberDo you identify as Aboriginal or Torres Strait Islander?YesNoIf yes (please tick) Aboriginal Torres Strait Islander Aboriginal and Torres Strait Islander Emergency ContactsNext of kin NameAddressHome PhoneMobile phoneRelationshipEmergency Contact (If different from NOK)NameAddressHome phMobile phRelationship It is very important for your healthcare that you inform us of any health issues past or present. For our Doctors to gather a proper patient history please answer the following questions honestly.Please tick anything that is relevant to you Smoker Contraception Depression Anxiety Schizophrenia Weight issues Immunisations Arthritis Warfarin/equivalent Blood pressure Heart Attack Heart Disease Ex-smoker Diabetic Thyroid problems Hysterectomy Asthma Use Insulin Past medical historyAllergiesList or leave empty for none.Current MedicationsList or leave empty for none.Current alcohol intakeNon-drinkerDrinkerDays per weekStandard drinks per dayPast alcohol intakeNilOccasionalModerateHeavyCurrent smokingNon-smokerEx-smokerSmokerYear startedPast smokingLightModerateHeavyYear startedYear stopped My Health Record - Forms attached (Australian Government Initiative) Have your registered your children for their My Health Record?YesNoEdgeworth Family Practice has issued me with the paperwork to register my child/childrenYesNoUpload Forms Drop files here or Accepted file types: doc, docx, jpg, jpeg, pdf. Allowed formats: Word, PDF and JPEG. Maximum file size 8MB.Have you registered for a My Health Record?YesNoI give permission for Edgeworth Family Practice to register me with “Assisted Registration”. I have read and accept the terms of the attached “Essential information about assisted registration and your privacy in the eHealth record system”YesNoI give permission for the Doctors and Nurses at Edgeworth Family Practice to upload my shared health summary if requiredYesNoHow did you hear about our surgery?FacebookWebsiteGoogleFamily or FriendsOtherI give consent for Edgeworth Family Practice to leave a nondescript message on my mobile phoneYesNoI give consent for Edgeworth Family Practice to leave a nondescript message on my home phoneYesNoDo you already have an appointment?*YesNoAppointment Time* : HH MM AM PM Appointment Date* Date Format: DD slash MM slash YYYY CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.