Medicare Card Number:
Please complete the following by selecting the correct answer.
Have you suffered from ....
Yes No High Blood Pressure
Yes No Diabetes
Yes No Heart disease including heart attack or angina
Yes No Lung disease including asthma
Yes No Stomach or bowel problems
Yes No Kidney disease
Yes No High Cholesterol
Yes No Thyroid disease
Yes No Brain disease, stroke or head injury
Yes No Mental illness including depression or anxiety
Yes No Cancer of any kind including skin cancer
Yes No Abnormal Pap smear (females only)
Yes No Prostate abnormalities (males only)
Yes No Skin disease includng Eczema and Psoriasis
Yes No Migraine or frequent headaches
Yes No Joint disease including arthritis and back pain
Yes No Have you had any operations?
Yes No Have you ever smoked?
Yes No Do you ever take alcohol?
Yes No Do you exercise regularly?
Yes No Do you take any regular medication?
Yes No Do you take vitamins, supplements or herbal therapies?
Has anyone in your family (parents, brothers, sisters or children) suffered from any of the following illnesses?
Yes No Unsure High Blood Pressure
Yes No Unsure Diabetes
Yes No Unsure Heart Disease
Yes No Unsure High Cholesterol
Yes No Unsure Breast Cancer
Yes No Unsure Thyroid Disease
Yes No Unsure Bowel Cancer
Yes No Unsure Other Illnesses
Thank you for your assistance.
In line with the provisions of the
Commonwealth Privacy Act (1988) and the National Privacy Principles
, you are asked to give your consent to Riverstone Family Medical Practice for the collection and storage of your personal and health information. The information you provide will form part of your medical record and be stored in our computer system.
It is necessary for us to collect personal information from our patients (and sometimes others associated with their health care) in order look after their health needs and for associated administrative purposes. No access to your health or other personal information, in any form, will be provided to any unauthorized person or to any person or organization outside of this practice without your permission.
In consideration of our doctors and other patients, if you are unable to attend or need to change your appointment, please provide us with as much notice as possible so we can offer that appointment to those on the waiting list. Cancellation of consultations less than 2 hours prior or missed will incur a $30 fee which is not claimable from Medicare or Private Health Insurers. Cancellation Policy:
How did you find out about our Practice?
1.   I consent to Riverstone Family Medical Practice recording and storing the information I have provided on this form. I understand that this information will form part of a computerised database.          Yes No
2.   I give my consent to Riverstone Family Medical Practice using the information I have provided to issue reminders and recalls to me and to send practice information by SMS, phone, email or letter. I understand that a third-party service may be used.          Yes No
3.   In the event that I need to be referred for further tests and/or investigations or to a specialist or other health professional, I give my consent to my doctor disclosing essential personal and health information for that purpose.          Yes No
5.   I have read and understood the written information given to me titled Cancellation Policy.          Yes No