Location Which practice would you like to register with?EdgecliffWoy WoyMirandaKiama Have you ever been treated here before?YesNo Patient's Details Patient's Name: Title:MrMrsMissDr Address: Suburb: State: Postcode: Sex:MaleFemale Date of Birth (dd/mm/yyyy): Age: Phone (Home): Phone (work): Mobile: Email: Patient's Occupation: Are you in a health fund?YesNo Fund Name: Card Number: Do you hold a Veterans Affairs Gold Card?YesNo Medicare card Number: We are grateful that our practice grows by referral. Who should we thank for referring you? General health Questions 1. How would you describe your general health?ExcellentGoodFairPoor 2. Are you under the care of a doctor for any medical conditions?YesNo If yes, please explain 3. Name and address of family doctor 4. Are you wearing a pacemaker or heart valve prosthesis or do you have a joint replacement or any other medical implant?YesNo If yes, please explain 5. Have you ever had abnormal bleeding associated with previous extractions, surgery or trauma?YesNo If yes, please explain 6. Are you taking any kind of medications (prescribed or non-prescribed) or drugs at this time?YesNo If yes, please explain 7. Have you been diagnosed as having HIV, AIDS (Acquired Immune Deficiency) or ARC (Aids Related Complex)?YesNo 8. Are you pregnant?N/ANoYesHow Many Months: 9. Are you allergic or have had an unusual reaction to any of the following (Please select all relevant). PenicillinCodeineSedativesAspirinSteroidsIbuprofenNitrous OxideErythromycinLatex! RubberSulpha DrugsValiumFlagyl If Other, Please State: 10. Do you have a history of any of the following disorders? (please select) Lung DiseaseSinus TroubleHeart TroubleHay FeverKidney TroubleTuberculosisHepatitis AHepatitis BHepatitis CBlood DisordersThyroid TroubleHeart AttackHeart MurmurConvulsionsEpilepsyDepressionMigraineSleep ApnoeaAnaemiaAsthmaHerpesArthritisDiabetesGlaucomaAnginaStrokePalpitationsStomach Ulcer/RefluxFainting SpellsChronic Bronchitis/CoughShortness of BreathRheumatic FeverCancer TreatmentPsychiatric TreatmentHigh Blood PressureHives or Skin Rash 11. Do you currently receive, or have you ever received, occasional injections by a doctor or specialist for Osteoporosis?YesNo 12. Have you ever taken any of the following medications (Please select) FosamaxActonelZometaDidrocalPamisolAlendroDidronelArediaBonivaSkelidBonefosAclasta 13. Is there anything else about your health we should know? I agree the above information is to the best of my knowledge are true and correct . Please select Yes for Acceptance:YesNo Today's date: We provide payment plan options for major Dental work. Please ask us for more information. Submit form
