Patient History

This form will take a few minutes to complete. Please have ready:

  • Your Medicare number
  • A list of any medications you are currently taking
  • The name of your regular doctor and medical clinic, if you have one
Patient details
Medical history
Have you been treated for a medical condition, or been admitted to hospital in the last 2 years? 

Do you have, or have you had any of the following medical conditions:

Allergies (e.g. foods/dairy, antibiotics, latex) 
High or low blood pressure 
Heart surgery (e.g. valve replacement, stent, bypass, or pacemaker/Implantable cardiac device (ICD)) 
Bone disease (e.g. osteoporosis) including bone altering medications (oral or infusions) 
Blood thinning medications (e.g. aspirin, warfarin, apixaban, dabigatran, rivaroxaban, clopidogrel, heparin) 
Intellectual/cognitive or physical disability requiring assistance (e.g. dementia, wheelchair, guide/therapy dog) 
A multi-drug resistant infection (e.g. golden staph – MRSA or VRE) 
Treatment for any form of cancer (e.g. surgery, radiotherapy, chemotherapy, immunotherapy) 
Heart disease/disorders (e.g. atrial fibrillation, Rheumatic fever, congenital disorders, heart attack) 
An organ transplant (e.g. kidney, liver, heart, lung, bone marrow) 
Lung disease (e.g. asthma, COPD/emphysema, cystic fibrosis, pneumonia) 
Neurological disorders (e.g. Epilepsy, motor neurone disease, Parkinsons, stroke) 
Blood borne viruses or liver disease (e.g. hepatitis B/C, or HIV) 
Diabetes or kidney disease (e.g. dialysis) 
Mental health issues (e.g. anxiety, depression, bipolar) 
Joint replacement surgery (e.g. hip or knee) 
Are you a current or past smoker? 
Do you have any disease, condition or problem not listed? (e.g. autoimmune disorders) 
Are you pregnant?
Patient declaration

Your updated information has been submitted. Thank you.

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Health Partners is committed to providing quality and affordable health care, and we value our members and our obligation to protect your privacy. As part of our responsibility in protecting your privacy, from time to time we review our policies to ensure we are meeting our obligations. We have recently made some updates to our Privacy Policy. Please click here to view the Health Partners Privacy Policy.

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