New Patient Questionnaire

New Patient Questionnaire
Before making an appointment we ask you to provide us with some background information. This will provide us with details on your current and past conditions, assist us in aligning you with the right specialist for your needs, and allow us to be more familiar with you upon your first visit with us.

This will only take you a few minutes. Once completed, our reception team will call you within 5 days to book an appointment.
Patient Name *

Prefix First Name Last Name
Parent/Guardian Name

Prefix First Name Last Name
Occupation
Ethnicity *

Address *

Date of Birth *

Day Month Year
Date Date Picker Icon
Phone Number *

Area Code Phone Number
Alternative Phone Number

Area Code Phone Number
Email *
example@example.com
National Health Index Code (NHI)
If known
Medical Insurance *

Southern Cross Sovereign NIB No Medical Insurance
Southern Cross Membership Number *
Would you like your consult letters to be sent to your General Practice? *

Yes No
GP Name
GP Address

	Yes	No
Have you ever had a skin reaction to Jewellery?
Have you ever had a skin reaction to Skin Care Products/Cosmetics?
Have you ever had a Patch Test?

	Yes	No
Asthma
Eczema
Runny nose (Rhinitis)/Hay Fever
Vomiting, Diarrhoea or Colic

	Yes	No
Do you have a cat?
Do you have a dog?
Are your symptoms better on holidays?
Are you worse at work?
Do you have any hobbies?

	Yes	No
Have you ever had an operation on your Sinuses?
Do you have High Blood Pressure?
Are you Diabetic?
Do you smoke?