North Rockhampton Medical Centre

Patient Information Update Form


PLEASE WRITE CLEARLY AND LEGIBLY


Title: _________ First Name:  ______________________________ Surname:  ____________________________________________
 

Preferred Name: ________________________ Date of Birth: ______/______/_________ Male / Female
 

Medicare Number: □□□□-□□□□□-         Ref no.□ Expiry: ____ /_______
 

(Please circle): Aboriginal / Torres Strait Islander / Aboriginal & Torres Strait Islander / Neither Aboriginal nor TSI
 

(Please circle): Pensioner Card / Veterans Affair Card / Health Care Card / Commonwealth Seniors Card
 

Concession Card Number:  _____________________________________ Expiry Date:_____/_____/_________
 

Private Health Cover: (Please circle): Yes / No - If Yes - Basic / Intermediate / Top
 

Residential Address: ___________________________________________________________________________________________

                                          No.    Street                                                            Suburb / City                         State               Postcode
 

Postal Address: as above or  __________________________ _________________________________________________________
 

Phone Number: Home  :_______________________ Work  _______:__________________ Mobile: __________________________
 

Marital status: (Please circle): Single / Married / Widowed / Divorced / Defacto / Separated
 

Occupation:  _______________________________________________
 

Country of Birth: Australia / Other-  __________________________________ Ethnicity:  __________________________________
 

Next of Kin: Name:  ___________________________________             Relationship to patient:  _____________________________
 

Home phone number:  ________________________________           Mobile number:  ____________________________________
 

Emergency Contact Person: as above / other - Name:  ____________________________________________________________
 

Relationship to patient:   _________________________________      Phone numbers:_____________________________________
 

Allergies: (Please circle): Nil known / Yes - Item, Nature of Reaction, Severity:     ______________________________________

______________________________________________________________________________________________________________

Asthmatic: (Please circle): Yes / No Diabetic: (Please circle): Yes / No
 

List any ongoing issue the patient may have:       __________________________________________________________________
 

Family history: (Please circle):   Nil  /  stroke   /   heart disease   /   diabetes   /   cancer   /   hypertension   /   depression

 

Living arrangements:   Patient lives with - (Please circle):    spouse   /   friend   /   relative   /   alone
 

Alcohol Intake: Non-drinker OR Days per week  ________           Standard drinks per day   __________
 

Smoking: (Please circle):   Non-smoker   /   Ex-smoker   /   Smoker - if Yes - No. per day   _________
 

Weight: _________kg Height: __________cm Waist measurement: _________ cm (if over 18 years)
 

How did you know about this Medical Centre?   Radio   /   Internet   /   Yellow Pages   /   Word of mouth   /   Signage
 

 

Signature: ____________________________________                  Date:      ______________________

  • Facebook - Black Circle
  • Twitter - Black Circle
  • Google+ - Black Circle
  • YouTube - Black Circle
  • Pinterest - Black Circle
  • Instagram - Black Circle

OPENING HOURS

Monday - Friday 8am to 5pm

Saturday 8:30am to 12:30pm

Sunday & Public Holidays - Closed