MrMrsMsMissMasterDrothers Ethnicity AustralianAboriginalTorres Strait Islander To whom should the account be addressed if the patient is a child: How did you hear about us? GoogleFacebookFamily/friend recommendationOther MEDICAL INFORMATION AllergiesNil known PLEASE TICK ANY RELEVANT PAST MEDICAL / SURGICAL HISTORY Heart DiseaseCancerAsthmaHigh Blood PressureMigraineStomach or duodenal ulcerHigh cholesterolStrokeEpilepsyDiabe tesBlood clotsDepression / Anxiety Other illness/surgery – please give details Please list current medications, including vitamins and mineral supplements IMMUNISATIONS Pneumococcal (pneumonia)InfluenzaTetanusChildhood vaccines up to dateOther (please specify) MEDICAL INFORMATION FAMILY HISTORY 1.Have any of your close relatives had heart disease before 60 years of age? Heart disease includes cardiovascular disease, heart attack, angina and bypass surgery. YesNo 2.Have any of your close relatives had diabetes? Diabetes is also known as type 2 diabetes or non-insulin dependent diabetes YesNo 3.Do you have any close relatives who had melanoma? YesNo 4.Have any of your close relatives had bowel cancer before 55 years of age? YesNo 5.Do you have more than one relative on the same side of the family who had bowel cancer at any age? Please think about your parents, children, brothers, sisters, grandparents, aunts, uncles, nieces, nephews and grandchildren. YesNo 6.Have any of your close male relatives had prostate cancer before 60 years of age? YesNo 7.Have any of your close female relatives had ovarian cancer? YesNo 8.Have any of your close relatives had breast cancer before 50 years of age? YesNo 9.Do you have more than one relative on the same side of your family who has had breast cancer at any age? Please think about your parents, children, brothers, sisters, grandparents, aunts, uncles, nieces, nephews and grandchildren.* YesNo 10.Is there a history of mood disorder in your immediate family? YesNo If there is a family history of cancer, please specify what kind LIFESTYLE HEALTH HISTORY (specify approximate month/year) Smoking history Never smokedFormer smokerCurrent smokerNumber of years smoking Alcohol Do you drink alcohol?YesNo INFANT PROFILE When was the baby born? Full TermPremature Mode of delivery NormalCaesareanForcepsVacuum extraction Feeding BottleBreast fed Are there any smokers in the household? YesNo × We Are HereHow Can We Help?Melbourne Greensborough Plaza, 6/35 Main St, Greensborough VIC 3088 (03) 9432 2336 61405298988Follow Us OnLet's talk.Book an Appointment With An Expert Doctor in Melbourne What Is The Appointment For? * Quit Smoking AdviceSkin Care TreamentPre-pregnancy CounsellingNutritional AdviceCOVID-19 TestOther Your Appointment Date
