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We also offer video consultation via Zoom or WhatsApp

631-633 Elizabeth Street, Waterloo, Sydney-NSW 2017
02 9698 3060
0452 205 396
After Hours Doctor: (02) 8724 6300
After Hours GP Helpline: 1800 022 222
admin@poetscornermc.com.au
management@poetscornermc.com.au
02 9699 6514

Surgery Opening Hours

Monday – Friday

9:00am – 5:00pm

Saturday

9:00am – 3:00pm

Sunday

Closed

Personal / Contact details:

Gender: MaleFemale

Marital Status:SingleDe FactoMarriedSeparatedDivorcedWidowed

Do you identify as being of Aboriginal or Torres Strait Islander origin?Yes, AboriginalYes, Torres Strait islanderYes, both Aboriginal and Torres Strait islanderNo

Do you agree to be put in our reminder system?: YesNo

Would you like to be contacted via SMS (mobile text message) for appointment reminders, recall, and other test reminders or medical services we offer? YesNo

How did you hear about us?InternetWord of mouthOther

Medicare / Health Care Card / Pension card:

GoldWhite

Emergency Contact:

Is this emergency contact same as Next of Kin: YesNo

Please provide details below:

Privacy policy

Poets Corner Medical Centre is committed to maintaining the confidentiality of your personal health information. It ls policy of this Practice to maintain the security of personal health information at all times and to ensure that this Information Is only available to authorised Practitioners.

Patient's Details

Alcohol Assessment

How often do you have a drink containing alcohol?NeverMonthly or less2-4 times a month2-3 times 3 week4 or more times a week

If You Answered Never, No Need To Answer The Following Questions

IF Yes, How many standard drinks containing alcohol do you have on a typical day? 1 or 23 or 45 or 67 - 910 or more

How often do you have 6 or more drinks on one occasion?NeverLess than monthlyMonthlyWeeklyDaily or almost daily

Smoking Assessment

Do you smoke cigarettes?YesNo

How long have you been smoking cigarette?

Planning to quit???YesNo

Family History Screening Questionnaire:

This risk assessment focuses on your close relatives, including parents, children, brothers, and sisters who are either living or dead. If answered yes to any question, please state who. *(Only first and second-degree relatives need to be considered in this screening questionnaire).

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

Have any of your close relatives had diabetes? ‘Diabetes | also known as type 2 diabetes or non-insulin dependent diabetes.YesNo

Do you have any close relatives who had melanoma?YesNo

Have any of your close relatives had bowel cancer before 55 years of age?YesNo

Do you have more than one relative on the same side of the family who had bowel cancer at any age?YesNo

Please think about your parents, children, brothers, sisters, grandparents, aunts, uncles, nieces, nephews, and grandchildren.

Have any of your relatives had prostate cancer before 60 years of age?YesNo

Have any of your close female relatives had ovarian cancer? YesNo

Have any of your close relatives had breast cancer before 50 years of ageYesNo

Do you have more than one relative on the same side of your family who has had breast cancer at any age?YesNo

631-633 Elizabeth Street, Waterloo,
Sydney-NSW 2017

admin@poetscornermc.com.au

02 9699 6514

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