New Patient Medical Form

Patient Name *

First

Last

Date of Birth *

Postal Address *

State *

Postcode *

Home Phone

Work Phone

Mobile

Email *

Medicare Number *

Expiry

IRN

Pension / Health Care Card Number

Private Health Fund Name

Health Fund Number

Dept. Veteran Affairs:

White
Gold

DVA Number

General Practitioner:

Medical Centre

Other Interested Parties

Next of Kin

Full Name

Relationship to you

Contact Number

Medical History Questions

Do you have Hypertension? (High blood pressure)

Yes
No

Do you have a bleeding problem / disorder?

Yes
No

Do you have kidney problems?

Yes
No

Do you have Abnormal Cholesterol? (Triglycerides)

Yes
No

Do you have Diabetes?

Yes
No

Do you have Peripheral Artery Disease? (Legs/Carotids)

Yes
No

Does your family have any history of heart conditions?

Yes
No

Please provide details

Has anyone in your family had an angioplasty (heart artery stent)?

Yes
No

Please provide details

Do you have a Pacemaker?

Yes
No

When was it installed? What brand do you have?

Do you have a Biventricular Pacemaker?

Yes
No

When was it installed? What brand do you have?

Do you have an ICD (Implantable Cardiac Defibrillator)?

Yes
No

When was it installed? What brand do you have?

Do you have a Loop Recorder?

Yes
No

When was it installed? What brand do you have?

Are you on any medication?

Yes
No

Please list all the medication you are taking including all prescription & non-prescription medications. (only if not listed on referral)

PATIENT CONSENT TO COLLECT & DISCLOSE INFORMATION

The Privacy Act of 1988 requires all health practitioners to obtain consent from their patients to collect, use and disclose patients’ information.

COLLECTION

Access Cardiology staff will collect information that is necessary for your treatment. Such necessary information may include:

♥ Full medical and psychological history.
♥ Family medical and psychological history.
♥ Ethnicity.
♥ Medicare / Private health fund details.
♥ Billing and accounting information.
♥ Contact Details.

The information will normally be collected directly from you; however, there may be occasions when it will be necessary to collect information from other sources with your prior consent. These sources may include but are not limited to:

♥ Parents about children.
♥ Children about their family.
♥ Schools and teachers.
♥ Other health care providers.

In emergency situations we may have to collect information from relatives or other sources without your prior consent.

USE AND DISCLOSURE

With your consent we will use and disclose your information for purposes such as:

♥ Account keeping and billing.
♥ To reply to your referring doctor.
♥ Referral to another health care provider or hospital.
♥ Management of Access Cardiology including quality assurance, practice accreditations and complaint handling.
♥ To prevent or lessen a serious threat to an individual’s life, health or safety.
♥ Where legally required to do so e.g. by a court, mandatory reporting etc.
♥ To meet our obligations of notification to medical defence organisations or insurer.

ACCESS

You are entitled to have access to your own health records at any time convenient to all parties. Depending on the nature of the access requested a charge might be payable where the practice incurs costs in providing access. There are some circumstances in which access may be denied, but in such an event you will be advised of the reason. If you find any information we hold on you is inaccurate or incomplete, please advise us so that we can adjust your record. We are not able to erase the original record.

Signature

Date / Time

Time

Next of Kin

Medical History Questions

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