Patient Information and Medical History Form

PATIENT INFORMATION AND MEDICAL HISTORY FORM

TITLE: Dr /Mr/ Mrs/ Miss/ Ms/Master (PLEASE CIRCLE)

NAME ______DATE OF BIRTH:______

ADDRESS:______

______

PHONE (HOME):______(MOBILE):______

EMAIL:______

EMERGENCY CONTACT:______PHONE(H):______

MAY WE DISCUSS YOUR APPOINTMENT DETAILS WITH YOUR FAMILY MEMBERS OR

DRIVER/CARER: YES / NO

MEDICARE NUMBER:______REF NUMBER:______EXPIRY DATE:______

DVA NUMBER:______Gold or White (please circle)

PENSION NUMBER:______EXPIRY DATE:______

PRIVATE HOSPITAL FUND:______MEMBERSHIP NUMBER ______

GP NAME /ADDRESS:______

OPTOMETRIST NAME/ADDRESS:______

PRIVACY STATEMENT

This form contains personal and sensitive information about you. This information is collected by this practice for the provision of the best health care for you. This information may be used for your health care, any insurance claim or other matter relating to your health care. This information may be disclosed to other health service providers, a statutory health authority, insurers, debt collectors or other health practitioners. In order to provide the highest quality health care it may be necessary to obtain further health and/or personal history from other health care providers or family members. Your completion of this form implies your consent to the collection, use and storage of the information herein.

Signature______Date:______Please turn over and complete other side

GENERAL HEALTH Have you had any of the following? Yes No Diabetes Type 1 / Type 2 (CIRCLE) Duration:______years Heart Disease High Blood Pressure Stroke Blood Disorders (e.g. anaemia, bleeding disorders) Hepatitis or Other Liver Disease Asthma or Emphysema (CIRCLE) Cancer Type: EYE HEALTH Have you had any of the following? Glaucoma Macular Degeneration Retinal Detachment Lazy Eye

PREVIOUS EYE SURGERY DATE Cataract surgery Right Left Laser refractive surgery Right Left Retinal detachment surgery Right Left Other eye surgery (give details)

DO YOU HAVE ANY OTHER HEALTH PROBLEMS – Please give details

MEDICATIONS: Please list all current medications including eye drops and natural therapies. TABLETS EYE DROPS (CIRCLE) Right / Left Right / Left Right / Left Right / Left Right / Left

Are you taking WARFARIN Yes No PLAVIX Yes No ASPIRIN Yes No

ALLERGIES: Are you allergic to any medications? Yes No Are you allergic to IODINE / BETADINE / LATEX Yes No If Yes, please list allergies: ______

______

Have you ever had an adverse reaction to any anaesthetic? Yes No

Are you a current or previous smoker? □ Yes □ No □ Stopped ______years ago

Signature:______Date:______