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
27/07/2024
27/07/2024
27/07/2024
27/07/2024
27/07/2024
27/07/2024
27/07/2024
27/07/2024
27/07/2024
27/07/2024
27/07/2024
27/07/2024
27/07/2024
Medical history
Have you been treated for a medical condition, or been admitted to hospital in the last 2 years? *
27/07/2024
27/07/2024
27/07/2024

Do you have, or have you had any of the following medical conditions:

27/07/2024
Allergies (e.g. foods/dairy, antibiotics, latex) *
27/07/2024
High or low blood pressure *
27/07/2024
Heart surgery (e.g. valve replacement, stent, bypass, or pacemaker/Implantable cardiac device (ICD)) *
27/07/2024
Bone disease (e.g. osteoporosis) including bone altering medications (oral or infusions) *
27/07/2024
Blood thinning medications (e.g. aspirin, warfarin, apixaban, dabigatran, rivaroxaban, clopidogrel, heparin) *
27/07/2024
Intellectual/cognitive or physical disability requiring assistance (e.g. dementia, wheelchair, guide/therapy dog) *
27/07/2024
A multi-drug resistant infection (e.g. golden staph – MRSA or VRE) *
27/07/2024
Treatment for any form of cancer (e.g. surgery, radiotherapy, chemotherapy, immunotherapy) *
27/07/2024
Heart disease/disorders (e.g. atrial fibrillation, Rheumatic fever, congenital disorders, heart attack) *
27/07/2024
An organ transplant (e.g. kidney, liver, heart, lung, bone marrow) *
27/07/2024
Lung disease (e.g. asthma, COPD/emphysema, cystic fibrosis, pneumonia) *
27/07/2024
Neurological disorders (e.g. Epilepsy, motor neurone disease, Parkinsons, stroke) *
27/07/2024
Blood borne viruses or liver disease (e.g. hepatitis B/C, or HIV) *
27/07/2024
Diabetes or kidney disease (e.g. dialysis) *
27/07/2024
Mental health issues (e.g. anxiety, depression, bipolar) *
27/07/2024
Joint replacement surgery (e.g. hip or knee) *
27/07/2024
Are you a current or past smoker? *
27/07/2024
Do you have any disease, condition or problem not listed? (e.g. autoimmune disorders) *
27/07/2024
Are you pregnant?
27/07/2024
27/07/2024
27/07/2024
27/07/2024
Patient declaration
27/07/2024
27/07/2024
27/07/2024
27/07/2024

Your updated information has been submitted. Thank you.

© Copyright Health Partners. 2024 All Rights Reserved.

Health Partners is committed to providing quality and affordable health care, and we value our members and our obligation to protect your privacy. As part of our responsibility in protecting your privacy, from time to time we review our policies to ensure we are meeting our obligations. We have recently made some updates to our Privacy Policy. Please click here to view the Health Partners Privacy Policy.

Youtube Facebook site by evolution 7

Contact Us

1300 113 113 Sat 9am - 1pm

Send us a message

Dental

1300 114 114

Request appointment

Optical

1300 115 115

Book an eye test

Contact options and opening hours

View all