We are committed to providing our patients with the best care. To do this it is essential that your health record is kept up to date and accurate. Could you please assist us by completing the following:
Mr.Mrs.Other
Marital Status:SingleDe factoDivorcedMarriedWidowed
Interpreter required:YesNo
Do you give permission for the practice to access and record your IHI number?YesNo
To assist with health initiatives - are you:Yes - AboriginalYes - Torres Strait IslanderYes - Aboriginal & Torres Strait IslanderOther
Will Lockridge Medical Centre be your Regular GP Practice?YesNo
Tobacco:NO - Never SmokedNO - CeasedYES - CURRENTLY
Current medications (including over the counter medications, vitamins and minerals):
Do you have or have you had a history of?OperationsAsthmaDiabetesHypertensionChronic illnessOther
Do you have any allergies or are you sensitive to drugs or dressings:YesNo
Family History - have any members of your family had:DIABETESASTHMAHEART DISEASEMENTAL ILLNESSCANCER
Children's immunisations - if completing this form for a child are their immunisations up to date?YesNo
Immunisations - have you had the following immunisations?Tetanus boosterHepatitis BHepatitis AInfluenzaPneumococcalPolio
