Mr.Mrs.Other

Marital Status:SingleDe factoDivorcedMarriedWidowed

Interpreter required:YesNo

To assist with health initiatives - are you:Yes - AboriginalYes - Torres Strait IslanderYes - Aboriginal & Torres Strait IslanderOther

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