New Patient Medical History Form
You are no obligation to provide this information, however it does help establishing your file with us. Information provided to us is treated with the utmost respect and confidentiality.
www.torrensclinic.com
Patients Name
Your answer
DATE OF BIRTH
Your answer
ADDRESS
Your answer
PHONE NUMBERS
Your answer
MEDICARE NUMBER
Your answer
SMOKING STATUS
Your answer
Past Medical History
Your answer
Medications ( including dosages )
Your answer
Allergies ( Including reaction )
Your answer
Family History ( medical )
Diabetes / Heart disease / stroke / cancer.......etc at who had what
Your answer
Previous Workcover Claims
Previous Motor Vehicle Accident Claims
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