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 ORDRIVER/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 / NoDiabetes 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:______