New patients

New Patient Form

Please complete the form below ahead of your first appointment. Prefer email? Write to admin@drmccaffrey.com.au instead.

Leave this field blank if you're human:

Personal information

Name

Date of birth

Occupation

Full address, city & postcode

Mobile phone

Home phone

Emergency contact name

Emergency contact number

Referral

Referring GP / specialist details

Where did you hear about Dr McCaffrey?

Insurance information

Medicare number

Medicare reference number

Do you have private health cover?

Yes No

Level of private cover

Private fund

Private fund member number / ID

Medical history

Do you have any medical conditions?

Any previous surgeries?

Any family history of medical conditions?

Current medications or supplements

Any known allergies?

Women's health screening

Most recent cervical screening test (Pap smear)

Mammogram — year & result

Obstetric history

If any of the following apply, please give brief details.

Have you ever been pregnant?

Ectopic pregnancy?

Miscarriage?

Termination of pregnancy?

Birth details

For each previous birth, please include name / sex / date of birth / hospital / gestation / birth weight / mode of delivery.

Birth #1

Birth #2

Birth #3

Birth #4

Pregnancy complications

Any pregnancy complications?