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MEDICAL INFORMATION(cont)
IMMUNISATIONS:
 Pneumococcal (pneumonia)
 Influenza_______month_______year
_______month_______year
 Tetanus_______month_______year
 Other __________________ _______month_______year
OR
 Childhood vaccines up to date
If you have evidence of Immunisation, please provide a copy for your records.
WOMEN’S HEALTH:
MEN’S HEALTH: (if over 40year old)
Last Pap Smear:
_______month_______year
Last prostate check: _______month_______ year
Was the result negative or other
Would you like a reminder when your next papsmear is due yes or no
Last Mammogram: _______month_______year
LIFESTYLE HEALTH HISTORY:
Smoking
 Never  Current smoker: ______ Per Day  Former smoker: ______Date Quit
Alcohol
(Standard Drinks)
 Never  Drinker: ______ Per Day OR ______ Per Week
Have you ever had?
Mothers History?
Fathers History?
Alive/Deceased Age at Death
Alive/Deceased Age at Death
 Diabetes
 Diabetes
 Diabetes
 Heart disease
 Heart disease
 Heart disease
 Hypertension
 Hypertension
 Hypertension
 Stroke
 Stroke
 Stroke
 Asthma
 Asthma
 Asthma
 Cancer
 Cancer
 Cancer
In accordance with the Privacy Act (1988), all information collected in this practice is treated as “sensitive information”. To protect your privacy,
this practice operates in accordance with the Act.
We use the information you provide to manage your health care. You can assist in maintaining the accuracy of your information by advising the
practice of changes of address, phone number etc.
Selected information may be disclosed to various other health services involved in supporting your health care management, (e.g. Pathology &
Radiology)
Please Note – Due to privacy laws it is preferred that adults and over sixteens arrange their own appointments whene
ver possible. Results cannot be given to a third party except under special circumstances.
CONSENT- PLEASE TICK BOXES
 I consent to the use of my personal health information by Whitsunday Family Practice and other health providers
involved in my medical treatment and health care.
 I consent to the disclosure of my personal health information by the above named practice to other health
providers directly or indirectly involved in my personal health care or medical treatment
Patient Signature/Parent or Guardian: ____________________________ Date: ______/______/______
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