New Patient Information Patient Information Step 1 of 4 25% Name* PrefixMrMrsMissMsMxOtherNone Prefix First Last PronounsPreferred NameDate of Birth* DD slash MM slash YYYY Address* Street Address City State / Province / Region ZIP / Postal Code Different Postal AddressDifferent Postal Address? Yes Postal Address Street Address City State / Province / Region ZIP / Postal Code Aviation Reference NumberContact DetailsHome PhoneWork PhoneMobile PhoneEmail SMS Reminder*Would you like to receive SMS appointment reminders? YES NO Aboriginal/Torres Straight Islander*Do you identify as being of Aboriginal and/or Torres Strait Islander origin? YES NO Next of KinPrimary Contact First Last Contact 1 - Relationship Contact 1 - Home PhoneContact 1 - Work PhoneContact 1 - Mobile PhoneSecondary Contact First Last Contact 2 - Relationship Contact 2 - Home PhoneContact 2 - Work PhoneContact 2 - Mobile Phone Medicare / Private HealthMedicare Number*Medicare Reference No.*Medicare Expiry Date*If you are aged 25 and Under and still listed on your parents Medicare Card, please complete card holder information belowMedicare - Card HolderMedicare - Card Holder DOB DD slash MM slash YYYY Medicare - Card Holder AddressPrivate Health InsurerPrivate Health NumberPrivate Health CoverPrivate Health DVA No.DVA Card ColourCard ColourGOLDWHITEPension Card NumberPension Card ExpiryReferring DoctorReferring PracticeReferrer CheckWhere you referred by your regular GP? Yes No Regular GP Patient Medical Conditions QuestionnaireDiabetesHave you been diagnosed with diabetes? Yes No Diabetes - Year of DiagnosesDiabetes - InsulinAre you currently taking insulin? Yes No Diabetes - Year commenced insulinDiabetes - DizzinessDo you suffer from dizziness on standing up? Yes No Diabetes - VomitingDo you suffer from vomiting after meals? Yes No Diabetes - Eye ProblemsAny diabetes related eye problems? Yes No Diabetes - Eye DetailsDiabetes - Eye SpecialistDiabetes - Eye ReviewDiabetes - PodiatristDo you see a podiatrist regularly? Yes No Diabetes - Foot UlcerHave you ever had a foot ulcer? Yes No Diabetes - Calf PainDo you feel pain in your calf that stops you walking? Yes No Diabetes - Calf Pain DistanceDiabetes - Feet ProblemsBurning, tingling, painful feet? Yes No Other Conditions - Blood PressureDo you have high blood pressure or currently receiving treatment for high blood pressure? Yes No Other Conditions - CholesterolDo you have high cholesterol or currently receiving treatment for cholesterol? Yes No Other Conditions - Smoker (Current)Are you a smoker? Yes No Other Conditions - Smoker (Current) Cigarette CountOther Conditions - Smoker (Ex)Are you an ex-smoker? Yes No Other Conditions - Smoker (Ex) Quit YearOther Conditions - Heart AttackHave you ever suffered from a heart attack? Yes No Other Conditions - Stent or AngioplastyHave you received a coronary artery stent or undergone an angioplasty? Yes No Other Conditions - Bypass SurgeryHave you undergone coronary artery bypass surgery? Yes No Other Conditions - Heart FailureHave you ever suffered from heart failure? Yes No Other Conditions - ThyroidHave you ever suffered from thyroid problems? Yes No Other Conditions - Thyroid (Details)Other Conditions - AsthmaDo you suffer from asthma? Yes No Other Conditions ListPlease list any other medical conditions you have: Operations/Surgery ListPlease list any operations/surgery you have had in the past: Allergies ListPlease list any allergies you have: Vaccinations ListPlease list any vaccinations you have had in the last 12 months Medications ListPlease list all current medications:NameDosage (e.g. 150mg)Frequency (e.g. 2 times a day) To complete this form you must understand and consent to the Geelong Endocrinology and Diabetes Services Privacy Policy, including: The types of personal information collected by the Practice, the reasons why it is necessary to collect it and the circumstances in which my personal information may be used or disclosed; That I may request access to my personal information, which may be granted in accordance with the Practice’s Access to Personal Information Policy. I will be provided with a written reason if access is denied; That I may request an amendment to my personal information if it is incorrect. I will be provided with a written reason if a request for amendment is denied; That my personal information will not be used for direct marketing or disclosed to overseas recipients; That I am not obliged to provide the Practice with my personal information, but withholding information may limit the Practice’s ability to provide me with full service. That should I choose to enter into email communication with the practice, I accept the risk that this is not an encrypted email service. That I have the right to lodge a complaint about the handling of my personal information if I am dissatisfied, which will be dealt with in accordance with the Practice’s complaint handling procedure. Privacy Policy Consent*If you agree to the practice privacy policy please enter your name here.CAPTCHACommentsThis field is for validation purposes and should be left unchanged. Δ