Dr Kieran McCaffrey

About Me

New Patient Form

About Me

New Patient Form

Name

Date of Birth

Full Address, City & Postcode

Mobile Phone

Home Phone

Emergency Contact Name

Emergency Contact Number

REFERRING GP/SPECIALIST DETAILS:

MEDICARE NUMBER

REFERENCE NUMBER

MEDICARE EXPIRY

DO YOU HAVE PRIVATE HEALTH COVER?

LEVEL OF PRIVATE COVER:

PRIVATE FUND & MEMBER NUMBER

DO YOU HAVE A HEALTH CARE CARD OR PENSIONER?

HEALTH CARE CARD / PENSION NUMBER?

DO YOU HAVE ANY MEDICAL CONDITIONS?

ANY PREVIOUS SURGERIES?

LIST OF CURRENT MEDICATIONS OR SUPPLEMENTS?

ANY KNOWN ALLERGIES?

WHEN WAS YOUR MOST RECENT CERVICAL SCREENING TEST (PAP SMEAR)?

EVER HAD A MAMMOGRAM / WHAT YEAR / RESULT NORMAL OR ABNORMAL?

HAVE YOU EVER BEEN PREGNANT? (IF SO, HOW MANY PREGNANCIES? AND WERE THEY VAGINAL OR BY CAESAREAN SECTION?)

HAVE YOU HAD AN ECTOPIC PREGNANCY? (IF SO, HOW MANY)

HAVE YOU HAD A MISCARRIAGE? (IF SO, HOW MANY)

HAVE YOU HAD A TERMINATION OF PREGNANCY? (IF SO, HOW MANY)

Any Additional Births?

BIRTH # 5

BIRTH # 4

BIRTH # 3

BIRTH # 2

BIRTH # 1