Patient Questionnaire

First Name *

Last Name *

Date of Birth *

dd/mm/yyyy

Identify as *

• Male
• Female
• Non-binary
• Gender diverse
• Transgender
• Different identity

Pronouns

• She/her/hers
• He/him/his
• They/them/theirs

Home address *

Suburb *

Post code *

Best contact number - mobile or landline *

Email Address *

Medicare Number *

Reference Number *

Medicare Expiry Date *

mm/yyyy

Veterans Affairs Number (if applicable)

Existing Medical Conditions (if any)

Medication list

Smoking status *

• Non-smoker
• Ex-smoker
• Smoker

Allergies (if any)

How did you find out about us?

• Recommended by friend/family
• Recommend by another doctor/health professional
• Just walking past

Recommended by (if applicable)

Comment or Message

Please ring the practice to make an appointment by calling 02 98293033

By submitting this form and when you are a regular patient of this practice, you agree to receive clinically relevant recalls and/or reminders via text or email.

Submit

2021-09-21