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Burwood Brickworks Medical Centre
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About Us
Mission
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Patient Registration
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Patient Details
Title
*
Surname
*
Given Name/s
*
Date of Birth
*
DD slash MM slash YYYY
Gender
*
Please select
Male
Female
Other
If other, please specify
*
Marital Status
*
Please select
Single
Married
Defacto
Separated
Divorced
Widowed
Medicare No.
*
Ref No.
Expiration Date
Pension, Health Care Card or DVA White/Gold Card Number:
Expiration Date
Occupation
Employer
Home Address
*
Postcode
*
Postal Address
*
Postcode
*
Email
*
Phone (Home)
Phone (Work)
Phone (Mobile)
*
Next of Kin
Name
*
Relationship to you
*
Phone (Mobile)
*
Phone (Home)
Phone (Work)
Emergency Contact
Name
*
Relationship to you
*
Phone (Mobile)
*
Phone (Home)
Phone (Work)
Do you identify as someone from a culturally and/or linguistic diverse background?
*
Yes
No
If yes, Please indicate ethnicity
*
To assist with health initiatives - are you Aboriginal or Torres Strait Islander?
*
Yes - Aboriginal
Yes - Torres Strait Islander
Yes - Aboriginal & Torres Strait Islander
No
Health Questionnaire
Allergy to medication or food?
*
Yes
No
Unknown
If yes, Please specify
*
Smoker Status
*
Never Smoked
Ex-Smoker
Smoker
If Ex-Smoker, Please specify year quit
If Smoker, Please specify no per day
Alcohol Intake
*
Nil
Yes
If yes, please choose standard drinks/per
*
Day
Week
Month
No of drinks
*
Recreational Drugs
*
Yes
No
Regular Medications
*
Nil
Yes
If yes, Please list below any medications and their doses if known – include over the counter medications and supplements
*
Add
Remove
Current/Previous Medical Conditions
*
Nil
Yes
If yes, please tick any that apply
*
Asthma
Diabetes Type 1/Type 2
Heart Attack (MI)
Stroke/CVA
Pacemaker
DVT
Emphysema
Depression and/or Anxiety
Cancer
HIV/AIDS
Hepatitis A / B / C
Epilepsy
Other
Please specify Cancer type
If other, please specify
*
Family Medical History
*
Nil
Yes
If yes, Please list below
*
Relation to you (e.g., mother, grandfather, sibling)
Condition/s
Add
Remove
Our practice undertakes research, professional development, and quality assurance/improvement activities to improve patient care. All people accessing personal health information for this purpose have signed a written confidentiality agreement.
I consent to my health record being reviewed and uploaded to My eHealth Record as a part of the quality improvement activities in this practice.
*
Yes
No
I give permission for my personal information to be collected, used and disclosed as described in this practice policy. I understand only my relevant personal information will be provided to allow the above actions to be undertaken and I am free to withdraw, alter or restrict my consent at any time by notifying this practice in writing.
*
Yes
No
Our practice uses a reminder system to improve the quality of your health care. The practice sends reminders by mail or telephone for procedures such as vaccinations, pap smears and other health reviews.
*
Yes
No
I consent to being contacted with reminders by sms/phone/email
*
Yes
No
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