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Medical history update
Patient Name
(Required)
First
Last
Date of Birth
(Required)
Day
Day
1
2
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5
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11
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31
Month
Month
1
2
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11
12
Year
Year
2027
2026
2025
2024
2023
2022
2021
2020
2019
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2015
2014
2013
2012
2011
2010
2009
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1928
1927
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1925
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1923
1922
1921
1920
Address
(Required)
Address
Suburb
State
Postcode
THIS INFORMATION IS CONFIDENTIAL
and is necessary to enable us to offer you
THE BEST POSSIBLE CARE
. It is now mandatory to have a written updated medical history every two years and we would appreciate your time in thoroughly completing this form.
Are you currently or have you taken any medication or dietary supplements in the last 12 months?
(Required)
Yes
No
(If YES, please list below)
(Required)
Allergies/Reactions?
(Required)
Yes
No
(If YES, please list below)
(Required)
Have you ever had or are you suffering from any of the following? Please tick any that apply
Rheumatic Fever
Epilepsy
Asthma
Tuberculosis
Radiation Therapy
Dizziness, Fainting
Hepatitis A, B or C
Recent Eye Surgery
Diabetes
Kidney Disease
Heart Attack
Heart Rate Problems
Heart Murmur
High Blood Pressure
Bleeding Problems
Artificial Joints
Respiratory Problems
HIV Positive
High Cholesterol
Cancer
Pacemaker
Osteoporosis
Seizures
Acid reflux
Sleep Apnea
Do you have any disease, condition or problem not listed above?
(Required)
Yes
No
(If YES, please give details)
(Required)
Have you ever had surgery or been to hospital in the last 5 years?
(Required)
Yes
No
(If YES, please give details)
(Required)
For Women: Are you pregnant?
(Required)
Yes
No
(If YES, how many months along?)
(Required)
Do you currently or have you ever Smoke / vape?
(Required)
Yes
No
Have you ever had / are you prone to cold sores?
(Required)
Yes
No
Consent
The Information that I have provided is to the best of my knowledge, true and I understand that it is my responsibility to inform the practice of any changes in my medical status.
Signature of Patient/Parent/Person Responsible
Date
(Required)
DD slash MM slash YYYY
