New Patient Information Form
We are committed to providing our patients with the best care.
To do this it is essential that your medical records are up to date and accurate.
Could you please assist us by completing the following information!
Title Miss Mrs Ms Mr Dr Master Miss Other (please circle)
Family Name: …………………………………………………………………….. 
Given Name: ……………………………………………………………………….
Middle Name: …………………………………………………………………….. 
Preferred Name: ………………………………………….……………………….
DOB: ……………….. Sex: Male Female (please circle) 
Ethnicity: (please circle) Aboriginal Torres Strait Islander/ Aboriginal/ Non Aboriginal /Torres Strait Islander/Australian/ Other……………………………..
Address: …………………………………………………
City/Suburb: ……………………………………………..
Postal Address (if different): ………………………………………………………………………….
Home Phone: ……………………………….	
Work Phone: ………………………………..
Mobile Phone: ………………………………Email: …………………………………………………
Preferred contact: Home Phone	Work Phone	Mobile Phone (please circle)
Do you consent to SMS reminder messages Yes/No (please circle)
Medicare no: ………………………………..Ref#.............Expiry#.................
Pension/ Health Care Card # .………………………….... Expiry#.................
Pension card type: Pension concession/ Health care/ commonwealth seniors (please circle)
DVA no: ……………………………DVA type: Gold/ White/ Lilac / Orange (please circle)
Religion: …………………………...................
Head of Family: ……………………………….
Next of Kin: …………………………….Relationship: …………….Phone: ……………………
Emergency contact: …………………...Relationship: …………….Phone: …………………...
Your Occupation: ……………………………………
This question must be answered:
Do you have any allergies or are you sensitive to drugs or dressings: …………………………………………………………………………………………. 

How did you learn about FMP? (Please tick)
Face Book  Newspaper  Radio  Letterbox flyer  Word of mouth Shopping centre  Chemist  Family Attends  TV AD  White Pages  Yellow Pages / Online/  Directory Assist Other  ………………………………

Please turn over to complete……….

Reminder Systems:
Our practice provides our patients with preventive care and early case detection reminders, e.g. immunisations, annual health checks, skin checks and pap smears.

Do you wish to have any relevant health reminders sent to you?
•	Yes	 No
Do you have any health concerns you would like to receive more information about? 

Your health History- Do you have or have you had a history of?
 Operations
 Asthma
 Diabetes
 Hypertension 
 Chronic Illness
 Other

Immunisations- have you had the following immunisations?
Tetanus booster Date: ________________	 Don’t know	 Haven’t had one
Hepatitis B Date: _____________________	 Don’t know	 Haven’t had one
Hepatitis A Date: _____________________	 Don’t know	 Haven’t had one
Influenza Date: ______________________	 Don’t know	 Haven’t had one
Pneumococcal Date: _________________	 Don’t know	 Haven’t had one
Polio: _____________________________	 Don’t know	 Haven’t had one
Children’s immunisations- if completing this form for a child is their immunisations up to date?
 Yes		 No 
Current Medication (including over the counter medications, vitamins and minerals)

Family History- Has any members of your family had?
 Diabetes			Which family member___________________________
 Asthma			Which family member___________________________
 Heart Disease		Which family member ___________________________
 Mental illness		Which family member ___________________________
 Cancer			Which family member ___________________________
Social history
 Tobacco: __________ day / week or ceased smoking date_____________
 Alcohol: __________ day / week/ month (circle the one applicable)
Drug use: ____________________________________________ (type and frequency)
Height: _________ cms		Weight: _________ kgs
Blood pressure: When was the last time your blood pressure was taken? ______________

Please turn over to complete……….

Sun Protection: How often do you use the following to protect yourself from the sun when outdoors?
	Always	Often	Sometimes	Rarely	Never	
Protective clothing						
Sunscreen						

For those 65 years and older: When was the last time you were immunized? 
Influenza 	Date: __________  not sure		 never
Pneumoccoal pneumonia Date: __________  not sure		 never

Females: When did you last have?
Pap smear Date: __________  not sure		 never
Breast check Date: __________  not sure		 never

Males when did you last have?
An overall checkup Date: __________  not sure		 never

Patient Signature: _________________________ Date: ___________
Thank you for completing this form which will form part of your confidential medical record.
Your doctor may request additional information during your consultation.

FMP Woonona collects your personal details and health information to ensure we deliver the best possible healthcare service. Patients are entitled to access their information at any stage by contacting the practice or their GP. Your health information may be disclosed to other organisations over the course of your treatment and these instances will be discussed with you if required. Failure to provide accurate and comprehensive information could negatively affect your healthcare. If you have any concerns regarding your privacy, please contact the practice.