Confidential Patient Information Sheet printable pdf download

CONFIDENTIAL PATIENT INFORMATION SHEET

SURNAME....................................................................................................... Dr...Mr...Mrs...Ms…Miss...Mstr....

GIVEN NAME/S............................................................................................

(Defence only) RANK: …………………

DATE of BIRTH:......./......../.........

ADDRESS............................................................................................... SUBURB....................................................

Postcode: ............................................... Occupation: ...........................................................................................

PHONE: H (…...)....................................... W (......)........................................Mobile......................................................

Do you require an interpreter or language assistance? YES / NO

If patient under age 16 – Parent details:

Surname................................................... Given name/s......................................................DOB........./........./.........

Medicare card ref: ................................... (this is for online Medicare Claiming only)

Email Address:...............................................................................................................................................................

MEDICARE CARD NUMBER: __ __ __ __ __ __ __ __ __ __ Exp ....………/……………

Ref:................

PRIVATE INSURANCE NAME: ……………………………………………………........... Number:………………….............................

VETERANS' AFFAIRS CARD NUMBER: ..................................................................................... Gold/White

REFERRING DOCTOR........................................................

GP................................................................................

Person/Company responsible for account if not as above, Parent, Insurance Company, Employer:

...........................................................................................................................................................................................

PERSONAL MEDICAL HISTORY

Known Drug Allergies.........................................................................................................................................

Current Medications (including vitamins)…………………………………………………………………………………………....

List previous illnesses or operations.............................................................................................................

Do you take any of the following drugs daily?

Aspirin or Disprin

Yes / No

Insulin

Yes / No

Warfarin, Heparin or Xarelto

Yes / No

Cartia, Cardiprim or Plavix

Yes / No

Clopidogrel