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:______