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Patient Health Summary

Given Name (s)

Surname

Date of Birth

Date you were born

Height

In cm

Weight

In kilograms

Waist

Blood Pressure

Blood Sugar Level

Marital Status

Single Married Defacto Divorced Widowed

If you were born outside of Australia, what year did you arrive in Australia?

Have you had a Care Plan or Health Assessment recently?

Yes No Unsure

Warnings/Drug Allergies

Yes No

If you ticked 'Yes' please specify

Current Medication

Include Vitamins and Non Prescription Medication

Vaccinations (Please fill in dates for when you last had these Vaccines)

Hepatitis A

Hepatitis B

Tetanus

Pneumonia

Flu

Last Childhood

Other

Medical History

Cancer Origin

You Family Both

Diabetes

You Family Both

Epilepsy

You Family Both

Convulsions

You Family Both

Bleeding Disorder

You Family Both

Glaucoma

You Family Both

Heart Disease

You Family Both

High Blood Pressure

You Family Both

Kidney Disease

You Family Both

Mental Illness

You Family Both

Osteoporosis

You Family Both

Stroke

You Family Both

Thyroid Disease

You Family Both

Asthma

You Family Both

Other

If you ticked any of the above, Please specify further on when the diagnosis was made and Previous History.

To be completed for age 21 years and over

Females- Cervical Screen

Please fill in date of last Cervical Screen. If never had one write 'never'. If unsure write 'unsure'

Last Cervical Screen Result

Normal Abnormal Unsure

Females- Breast Check

Please fill in date of last Breast Check. If never had one write 'never'. If unsure write 'unsure'

Males- Overall Check Up

Please fill in date of last Overall Check Up. If never had one write 'never'. If unsure write 'unsure'

Social History

Tobacco

Yes No

If yes, please specify how many per day?

If you ceased smoking, Please enter date

Alcohol

Yes No

Drinks per Day

Drinks per Week

Drinks per Month

Drug Use

Yes No

If Yes, please specify type & frequency

By Communicating electronically with Berwick Healthcare, I dismiss the practice from all claims, losses, expenses and liabilities caused by any problems in using electronic mail with the risk of interception by third parties and non-recipients.

Yes

Email address

On campus with Federation university

Postal Address: PO Box 827, Berwick 3806 Location: 76 Clyde Road, Berwick Vic 3806 Phone: (03) 97961500 Fax: (03) 97961300 Email: reception@berwickhealthcare.com.au

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