University Medical Centre
          New Patient Registration Form

Given Names: ____________________________________	Surname: ________________________________________________
Birth Date (DD/MM/YYYY):   ____________________	  *Gender:   Male   Female  Other

*Marital Status:  ___ Married   Single   De Facto   Divorced   Widowed   Separated_______ 

Address: _______________________________________________________________________________________________________
Suburb: ________________________________				Post Code: ____________________________
Phone Home: ____________________  Work: __________________Mobile: _________________________

•	Student      	
•	Staff       	
•	Visitor	
UWA Student/Staff ID: _____________________UWA Student/Staff email: ________________________________________
Medicare No: ____________________________   Ref No (next to your name): ____     Expiry Date:  ____________
Centrelink HCC/Pension Card No:   ____________________________________              Expiry Date:  _____________
OSHC Policy Number (Allianz/Medibank): _______________________________           Expiry Date: _____________

Cultural Identity: *To Assist with Health initiatives	
*Aboriginal:     No    Yes                              *Torres Strait Islander:     No    Yes	
Country of Birth: ______________________________________________	
As Australia is a genuinely multicultural society, and to tailor appropriate care, encourage understanding and appreciation between people from different nationalities and cultures - do you identify as someone from a culturally and/or linguistic diverse background?
 No                        Yes - Please elaborate______________________________________________  
 Preferred Language _____________________________________________________________
If yes, do you require an interpreter service?   No    Yes	

Next of Kin		Phone Number:		Relationship		
Emergency
Contact Perth 		Phone Number:		Relationship		

Your Health Information	
ALLERGY INFORMATION - Do you have any allergies or are you sensitive to drugs or dressings?
 No
 Yes – provide details:___________________________________
MEDICAL HISTORY - Do you have or have you had a history of the following?
 Asthma
 Diabetes
 Hypertension
 Chronic Illness
 Other – provide details: 

CURRENT MEDICATIONS:

Recreational Drug Use 
 No 	
 Yes  - type_____________ frequency _________  	LIFESTYLE RISK FACTOR INFORMATION
Smoking  
 Never smoked           Ceased – date __________________  
 Yes - Frequency  Daily   Weekly   Less than Weekly                                                        
Alcohol 
 Never 	
 Yes  
How often do you have a drink containing alcohol:  
             monthly or less    2-3 times/month 
             2-3 times/week     4 or more times/week
How many per typical  day:
             1-2      3-4      5-6      7-9      10+
How often would you have 6 drinks or more on     
            one occasion?
             never  less than monthly   
             monthly  weekly   almost daily
Are you Concerned about your Alcohol Consumption?
  Yes   No  	
Have any members of your family have: 
 Heart Disease              Asthma                Diabetes                     Hypertension (high blood pressure)                           Mental Illness              Cancer – type:       Other significant - provide details:_____________________________	

PLEASE READ HEALTH INFORMATION CONSENT (ATTACHED) FORM AND COMPLETE BELOW
I have read the information attached and understand the reasons why my information must be collected.		
I understand that I am not obliged to provide any information requested of me, but failure to do so may compromise the quality of health care and treatment given to me.	
	
I am aware of my rights to access the information collected about me, except in some circumstances where access may be legitimately withheld. I will be given an explanation in these circumstances.		
I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained. If I am unsure I can discuss this further with someone from the medical practice before I sign.	
	
THE UNIVERSITY MEDICAL CENTRE COLLECTS AND SHARES DEINDENTIFIED DATA FOR QUALITY IMPROVEMENT PURPOSES.                                                      TO OPT OUT CLICK HER OR MORE INFORMATION SPEAK TO RECEPTION                                                                                	

Patient’s Name:………………………………………Patient’s DOB :…………………..……Patient’s signature: ………………………………..         
Signed as Guardian for child: ………………………………………….Name: (printed):  ………………………………………………………….