New Patient Questionnaire
This will take approximately 10 minutes to complete. It will allow us to be familiar with your history before your visit.
Patient Name
*
Mr.
Mrs.
Miss.
Ms.
Dr.
Other
Prefix
First Name
Last Name
Parent/Guardian Name
Mr.
Mrs.
Miss.
Ms.
Dr.
Other
Prefix
First Name
Last Name
Occupation
Ethnicity
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Date of Birth
*
-
Day
-
Month
Year
Date
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
Would you like your consult letters to be sent to your General Practice?
*
Yes
No
GP Name
GP Address
Back
Next
List your main symptoms or complaints (with duration)
*
List ALL medicines you take (including herbal, vitamins, etc)
Have you had Allergy Tests before?
*
Yes
No
Have you had immunotherapy (desensitisation) before?
*
Yes
No
Have you ever had a severe reaction to a Bee or Wasp sting?
*
Yes
No
How did this reaction manifest itself?
Have you ever had an Anaphylactic Reaction?
*
Yes
No
What was the cause?
Is your condition seasonal?
*
Yes
No
Which season is the worse?
How often do you have your attacks?
How long do they last?
Back
Next
Do you suffer any of these conditions?
*
Yes
No
Asthma
Eczema
Hives (Urticaria)
Hay Fever
Sinus Troubles
Frequent Colds
Persistent Cough
Diarrhoea
Abdominal Cramps
Comments
Contact Allergy
*
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?
Did you suffer from any of these conditions during childhood?
*
Yes
No
Asthma
Eczema
Runny nose (Rhinitis)/Hay Fever
Vomiting, Diarrhoea or Colic
Have any of your first degree relatives had Asthma?
*
Yes
No
Relationship
i.e. Mother, Father, Sibling
Have any of your first degree relatives had Eczema?
*
Yes
No
Relationship
i.e. Mother, Father, Sibling
Have any of your first degree relatives had Rhinitis (Hay Fever)?
*
Yes
No
Relationship
i.e. Mother, Father, Sibling
Do you suspect any foods as causing symptoms?
*
Yes
No
Which one(s)?
Are you omitting any food(s) at present?
*
Yes
No
Which one(s)?
Back
Next
Environmental History
*
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?
Are you sensitive or allergic to any Drugs?
*
Yes
No
Which one(s)?
Are your symptoms brought on or worsened by exercise?
*
Yes
No
General Medical History
*
Yes
No
Have you ever had an operation on your Sinuses?
Do you have High Blood Pressure?
Are you Diabetic?
Do you smoke?
Submit
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