Patient Details Form

QOMS will ask you to complete a Medical History Record upon arrival at our rooms before your initial consultation. Patients are welcome to complete this form and bring it with you on your initial visit.

Title(Required)

Preferred Name(Required)

First Name(Required)

Second Name(Required)

Surname(Required)

Date of Birth(Required)

Day

Month

Year

Home Address(Required)

Suburb(Required)

State(Required)

Postcode(Required)

Main Ph(Required)

Secondary Ph

Work Ph

Email(Required)

Occupation(Required)

Employer(Required)

Medicare Number(Required)

Reference Number(Required)

Medicare Expiry(Required)

Are you in a health fund for -

Private Hospital Cover(Required)

Yes

Extras Cover:(Required)

Yes

Name of Fund

Membership Number

Reference Number

Who is responsible for Fees?(Required)

Myself

Other

Other(Required)

Next of Kin(Required)

Contact Ph(Required)

Other Family Members Treated at QOMS

Have you ever been diagnosed with any of the following conditions?

Blood Pressure(Required)

High

Low

Asthma / Lung Disease(Required)

Yes

Diabetes(Required)

Yes

Heart Disease / Surgery(Required)

Yes

Heart Attack or Stroke(Required)

Yes

Prosthetic Joint eg knee, hip(Required)

Yes

Cancer(Required)

Yes

CanceraHIV / Hepatitis(Required)

Yes

Smoker(Required)

Yes

For Females, are you pregnant?

Yes

Please list other medical conditions

Please list any medications (prescription, over-the-counter, vitamin, or herbal)

Do you take ‘blood thinning’ medications?(Required)

Yes

Have you ever taken any medications for osteoporosis / bone density / bone cancer?(Required)

Yes

Please list any allergies

Have you ever suffered excessive bleeding following a cut or surgical procedure?(Required)

Yes

Do you require antibiotics prior to dental treatment?(Required)

Yes

Are you currently under the care of a general medical practitioner?(Required)

Yes

Name of Doctor(Required)

Suburb(Required)

Are you currently under the care of a dental practitioner?(Required)

Yes

Name of Doctor(Required)

Suburb(Required)

Are you currently under the care of a specialist medical practitioner?(Required)

Yes

Name of Doctor(Required)

Suburb(Required)

I herby consent to the use of this information as set out in the Privacy & Consent Statement below.

Date

DD slash MM slash YYYY

We require your consent to collect personal information about you. Please read this information carefully, and sign where indicated.

This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history so that we may accurately assess, diagnose, treat and be proactive in your health care needs. This means we will use the information you provide in the following ways:

1. Administrative purposes in running our practice.
2. Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
3. Disclosure to others involved in your health care, including treating doctors, specialists, and dentists outside this practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following the referrals.

I have read the information above and understand the reasons why my information must be collected. I am also aware that this practice has a privacy policy on handling patient information.

I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me.

I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances.

I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained. I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure of which I may notify this practice.

Patient Details Form

Patient Details Form

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