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Title DrMrMrsMsMissMaster
Surname
Given Name
Preferred Name
Date of Birth
Birth Gender MaleFemaleOther
Gender Identity MaleFemaleOther
Culture Australian (Non Indigenous)AboriginalTorres Strait IslanderThaiBrazilianVietnameseChineseIndianOther
Other Culture
Are you CTG Registered (ATSI patients only)
YesNoUnknown
Head of Family Name
Head of Family Date of birth
Street Address
Suburb and Post Code
Home Number
Work Number
Mobile Number
Email
Medicare Card Number
Ref Number
Exp
Pension/Health Care Card Aged PensionHealth Care CardOther
Number
DVA Card GoldWhiteOrange
Private Health Fund Company
Private Health Fund Number
Religion
Do you require an interpreter?
YesNo
Next of Kin Name
Address
Phone
Relationship
Emergency Contact Same as NOK? YesNo
Name
Mother Medical History HypertensionDiabetesHeart DiseaseCancerDepressionStrokeOtherUnknown (EG. Adopted)
Father Medical History HypertensionDiabetesHeart DiseaseCancerDepressionStrokeOtherUnknown (EG. Adopted)
Alcohol Intake Non-drinker
Days per week
Drinks per day
Tobacco Non-smokerSmokerEx-smoker
Year Started
Year Stopped
Do you have or have you had a history of: OperationsAsthmaDiabetesHypertensionChronic IllnessOther
Do you have any allergies or are you sensitive to drugs or dressings NoYes
Immunisations
Tetanus
Influenza
Pneumococcal
If completing this form for a child, are their immunisations up to date? YesNoNot sure
For those 65 years and older, when was the last time you were immunised for:
InfluenzaNot sureNever
PneumococcalNot sureNever
PneumoniaNot sureNever
ShinglesNot sureNever
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