Patient History

This form will take a few minutes to complete. Please have ready:

  • Your Medicare number
  • A list of any medications you are currently taking
  • The name of your regular doctor and medical clinic, if you have one
Patient details
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Medical history
Have you been treated for a medical condition, or been admitted to hospital in the last 2 years? *
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Do you have, or have you had any of the following medical conditions:

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Allergies (e.g. foods/dairy, antibiotics, latex) *
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High or low blood pressure *
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Heart surgery (e.g. valve replacement, stent, bypass, or pacemaker/Implantable cardiac device (ICD)) *
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Bone disease (e.g. osteoporosis) including bone altering medications (oral or infusions) *
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Blood thinning medications (e.g. aspirin, warfarin, apixaban, dabigatran, rivaroxaban, clopidogrel, heparin) *
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Intellectual/cognitive or physical disability requiring assistance (e.g. dementia, wheelchair, guide/therapy dog) *
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A multi-drug resistant infection (e.g. golden staph – MRSA or VRE) *
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Treatment for any form of cancer (e.g. surgery, radiotherapy, chemotherapy, immunotherapy) *
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Heart disease/disorders (e.g. atrial fibrillation, Rheumatic fever, congenital disorders, heart attack) *
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An organ transplant (e.g. kidney, liver, heart, lung, bone marrow) *
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Lung disease (e.g. asthma, COPD/emphysema, cystic fibrosis, pneumonia) *
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Neurological disorders (e.g. Epilepsy, motor neurone disease, Parkinsons, stroke) *
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Blood borne viruses or liver disease (e.g. hepatitis B/C, or HIV) *
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Diabetes or kidney disease (e.g. dialysis) *
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Mental health issues (e.g. anxiety, depression, bipolar) *
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Joint replacement surgery (e.g. hip or knee) *
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Are you a current or past smoker? *
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Do you have any disease, condition or problem not listed? (e.g. autoimmune disorders) *
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Are you pregnant?
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Patient declaration
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Your updated information has been submitted. Thank you.