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Registration

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Patient Registration Form

Title:

Surname:(Required)

First & Middle Name(s):(Required)

Preferred Name:

Date of Birth:

Sex:

Occupation:

Street Address:

Postal Address (if different):

Suburb:

State:

Phone:

General Medical Practioner (GP):

Address:

Phone:

General Dentist:

Address:

Phone:

MEDICARE & HEALTH INSURANCE DETAILS:

Medicare Details:

Medicare Card (Card No. 10 Digits on card):

Expiry Date MM/YY:

Ref No. (digit next to your name):

MEDICAL SUMMARY:

Have You Had or Currently Have:

Rheumatic Fever

No

Yes

Diabetes

No

Yes

Heart Problems

No

Yes

Heart Murmur

No

Yes

Epilepsy

No

Yes

Kidney Disease

No

Yes

Hepatitis

No

Yes

Asthma

No

Yes

High Blood Pressure

No

Yes

Osteoporosis

No

Yes

Stomach Reflux/ulcer

No

Yes

if yes, please provide details in box below (180 or less characters)

Have you smoked cigarettes/cigars within the last 4 weeks?

No

Yes

Are there any other "risk factors" you need to discuss in your consultation? (180 or less characters)

Have you EVER taken medications for osteoporosis or bone conditions/lesions? (eg. Fosamax, Actonel, Zometa, Pamisol, Didronel, Xgeva or Prolia):

No

Yes

Please list ALL medications you are currently taking (including non-prescription medications) (180 or less characters):

Please list ALL previous operations (180 or less characters):

Describe any serious illness you have previously suffered (180 or less characters):

General Anaesthetics:

Have you had problems with general anaesthetics or a family history of malignant hyperthermia? (180 or less characters):

Females:

Are you pregnant?

No

Yes

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