Name *

First Name

Last Name

Do you consent to SMS reminders?

Yes

Name *

First Name

Last Name

Name *

First Name

Last Name

Are you of Aboriginal or Torres Strait Islander Origin?

Yes

No

Smoking *

Non smoker

Ex smoker

Smoker

Alcohol *

Yes

No

Is your Mother alive? *

Yes

No

Other significant family history? *

Please tick.

Diabetes

Heart disease

Hypertension

Stroke

Breast Cancer

Depression

Colon Cancer

None of the above

Is your Father alive? *

Yes

No

Other significant family history? *

Diabetes

Heart disease

Hypertension

Stroke

Depression

Colon Cancer

None of the above

Do you have any known allergies? *

Yes

No

Do you suffer from any of the following? *

Please tick.

Diabetes

Heart disease

Hypertension

Stroke

Breast Cancer

Depression

Colon Cancer

Asthma

None of the above

We use a number of computer generated recall systems such as reminders for Pap smears, Diabetic reviews etc. These are all to enhance the efficiency of the practice and prevent patients missing important reviews with their doctors. If you do not wish to be included please tick the box.

Do not consent

Privacy Policy *

I have read and understand the privacy policy.

Name *

First Name

Last Name

Do you consent to SMS reminders?

Yes

Are you of Aboriginal or Torres Strait Islander origin?

Yes

No

Name *

First Name

Last Name

Privacy Policy *

I have read and understand the privacy policy.