New Patient Questionnaire

Confidential New Patient Questionnaire

Last Updated: 28/09/2021

Personal Details

Next of Kin

Contacting You

We require your permission to send SMS/emails to you regarding appointments, test results, health promotion recalls and practice updates


Information About You

Family History

Please state which member of your family have had any of the following conditions (eg. mother, father, maternal/paternal grandparent etc.)



Please complete the following audit. Unit of alcohol definition: Small glass of wine = 1.5 units Large glass of wine = 3 units 1 bottle = 10 units Pint of beer = 2 units Bottle of beer = 1.7 units Single shot of spirit = 1 unit

Veteran Status

Medical History


Please nominate a pharmacy to whom prescriptions can be transferred electronically (with your consent). This can be a pharmacy near your home address or work address. Please note that this will remain unchanged unless you inform us otherwise.


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