New Patient Health History Form Page 2
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2Smoking: Do you smoke? Yes No If yes how many per day ? _______________________________
Past Smoking History: Nil Light Moderate Heavy Which year did you stop smoking? ______________
Alcohol Consumption: Do you drink alcohol? Yes No If yes how much __________Days per week____________________
Past Alcohol Consumption: Nil Light Moderate Heavy
What is your Occupation? _____________________________Past Occupation:____________________
Patient History: Please circle the most appropriate answer fill out all other areas
Have you ever had : Diabetes
Kidney Disease
Asthma
High Blood Pressure
Heart Problems
Breast Cancer Colon Cancer Stroke
Depression Epilepsy Other Cancer
__________________________________________________________
Please list any operations or previous illnesses:
_______________________________________________________________________________________________
Do you know your blood group? Yes No If yes what group are you? ______________________________
FEMALE PATIENTS:
Please provide date of your last pap smear ______________
FAMILY HISTORY: Unknown (eg Adopted)
No significant family history
Other – see list below
Mother: Still alive: Yes No If no Age at Death: _________
Diabetes
Kidney Disease
Asthma
High Blood Pressure
Heart Disease
Breast Cancer Colon Cancer Stroke
Depression Epilepsy Other Cancer
Father:
Still alive: Yes No If no Age at Death: _________
Diabetes
Kidney Disease
Asthma
High Blood Pressure
Heart Disease
Breast Cancer Colon Cancer Stroke
Depression Epilepsy Other Cancer
Other immediate family members significant illness: ________________________
___________________________________________________________________
If this information is for your child please provide a copy of your child’s immunisation history to the receptionist.
At Golden Beach Medical Centre we strive to provide high quality care, appropriate to meet our clients health care requirements.
By becoming a patient of Golden Beach Medical Centre and signing this new patient form I agree and consent to the
following:
As part of our reminder service we will SMS you appointment reminders for extended, skin and recall appointments
I consent to the use of my personal health information by the Golden Beach Medical Centre and other health care providers
involved in my medical treatment and health care within this centre.
I consent to the disclosure of my personal health information by the above named practice to other health care providers involved
directly or indirectly involved in my personal health care or medical treatment.
As part of preventative health services offered by this practice we send out follow up reminders and recalls when routine
investigations are due. I consent to receive follow up reminders and recalls to be sent to the above address.
How did you find out about our surgery?
Word of Mouth
White Pages
Holiday Accom
Relatives
Bowls Club
Drive/walk past
Yellow pages
Leaflets/flyers
Pharmacy
Beyond Blue
Library Card
School Newsletter
A frame outside
Website
Signature______________________________________________________________ Date_______/________/________
Printed Name ____________________________________________
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Parent category: Medical