Medical History Form Personal DetailsTitle Full Name* Date of birth* DD slash MM slash YYYY Email* Phone (Mobile)* Phone (Home) Postal Address* Occupation Home Address Emergency Contact Details:Next of Kin - Name* Next of Kin - Phone* Medicare Details:Medicare No (10 Digits)* Your ID No* Expiry Date (mm/yyyy)* Veterans Affairs Details:Veterans Affairs Card No. Expiry Date (mm/dd/yyyy) MM slash DD slash YYYY Private Health Cover:Do you have private health insurance?* Yes No Do you have hospital cover?* Yes No Do you have dental cover?* Yes No Fund Name* Membership No.* Your Id No. Medical Info:Name of Regular GP Medical HistoryHeart disease* Yes No Rheumatic fever* Yes No Blood Pressue issues* Yes No Excessive bleeding* Yes No Hepatitis* Yes No Asthma / Bronchitis* Yes No Diabetes (Type 1 / Type 2)* Yes No HIV / AIDS* Yes No Epilepsy* Yes No Do you smoke?* Yes No Kidney problems* Yes No Osteoporosis* Yes No If Yes - Please list any medications you are taking, or have taken in the past (eg - Actonel, Fosamax, Prolia): Allergies?* Yes No Allergies - Please specify: Operations (Recent / Major)* Yes No Operations - Please specify: Other serious illnesses (Enter N/A if none):* List all medications/herbal supplements you are taking (Enter N/A if none):* Ladies, are you pregnant or breastfeeding? Yes No Terms* I agree to the terms below I understand that full payment of the account is my responsibility. In the event where your overdue account is referred to a collection agency and/or law firm, you will be liable for all costs which would be incurred as if the debt is collected in full, including legal demand costs. I will notify my surgeon of any change in my health or medication. Should further information be needed you have my permission to ask the respective health care provider, who may release such information to you.SignatureDate DD slash MM slash YYYY EmailThis field is for validation purposes and should be left unchanged.