New Patient Questionnaire Adelaide Street

Last Updated: 19/11/2020

Your Details

Name *

Date of Birth *

Height

Weight

Ethnic Origin / Country of Birth:

Main Language Spoken

Do you look after anyone

Does anyone look after you? If so please give details

Next of Kin

Medication and Allergies

Details of Current Medication (name of medication and dose)

Nominated Pharmacy

Do you have any allergies? If yes please specify.

Smoking

Do you smoke? *

Yes No

How many cigarettes a day?

Are you an ex-smoker? *

Yes No

When did you give up smoking?

Alcohol

How often do you have a drink that contains alcohol? *

How many standard alcoholic drinks do you have on a typical day when you are drinking? *

How often do you have 6 or more standard drinks on one occasion? *

General Information

During the last month, have you been bothered by feeling down, depressed or hopeless?

During the last month, have you been bothered by having little interest or pleasure in doing things?

Data Sharing

An informed patient, in consultation with a Healthcare Professional, you can choose or restrict access to the information entered into your record at each SystmOne organisation that accesses your record. You will be asked to give your record sharing consent at each organisation at which you receive care. Your consent can be changed at any time.

Sharing Out: Do you, the patient, consent to the sharing of data recorded here with any other organisation that may care for you? *

Yes - share data with other organisations

No - do not share any data recorded here

Consent not asked

Sharing in: Do you, the patient, consent to the viewing of data by this organisation that is recorded at other recorded care services that may care for you, where you have agreed to make the data shareable? *

Consent given

Consent refused

Consent not asked

Accessible Information

Do you have a disability, impairment or sensory loss & need to receive information in a way you can easily understand? *

I agree that I may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders.

Yes - please request an additional form from reception

Signature

Signature *

Date *

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

New Patient Questionnaire Adelaide Street

Further Information

Connect With Us