Patient Registration Form

General Information

please specify *

Gender *

FemaleMaleNon-binaryDifferent Identity

specify *

Sex assigned at birth *

FemaleMaleIntersex

First Name *

Surname *

Preferred Name *

Date Of Birth *

Address *

Suburb

Postcode

Occupation *

Relationship *

PartneredMarriedSingleOther

specify please *

Contact Details

Home

Mobile *

Email Address *

Language and Culture

Language spoken at home *

Do you require an Interpreter? *

YesNo

Cultural Background *

Indigenous Status

Are you of / or identify as Aboriginal or Torres Strait Islander decent? *

AboriginalTorres Strait IslanderBothNeither

Medical Information

Do you have medicare card?

Yes No

Medicare Card *

Ref No: *

Private Health Insurance *

YesNo

Fund Name *

Member # *

DVA

Blue Pension Card *

YesNo

Pension No: *

Referring Doctor *Answer NA if not applicable

Usual Doctor *

Medical History

Allergies *

Have you had a vasectomy? *

YesNo

Have you had a reversal if yes please provide details *

Have you ever had a semen analysis? *

YesNo

What year was this done? *

What Pathology Lab was it sent to? *

Do you have child/ren from a previous relationship? *

YesNo

Do you have a history of Anabolic steroid use? *

YesNo

Have you had Mumps in the past? *

YesNo

Have you every undergone Chemotherapy or Radiotherapy? *

YesNo

Do you have a history of undescended testes? *

YesNo

Have you ever had an Inguinal Hernia or Varicocele? *

YesNo

Do you have any erection or ejaculation concerns? *

YesNo

Past medical/surgical history *

Medical conditions that run in the family *Conditions that run in the family etc

Gynaecological/Obstetric History *

Current Medications *Including prescriptions/over the counter/vitamins

Are you on medication for inflammatory bowel disease? *

YesNo

Are you on blood thinners? *

YesNo

Are you on Diabetic medication? *

YesNo

BMI

Height *

Weight *

What is your smoking status? *

Current smokerNever smoked Ex Smoker

How many packs per day? *

What is your vaping status *

Currently VapeNever VapedEx Vaper

How often do you vape? *

Do you take illicit drugs? *

YesNo

What type of drugs and how often? *

Do you drink Alcohol? *

YesNo

How many standard drinks/day *

Have you had any other tests in relation to today’s appointment? *

YesNo

Ultrasounds/Bloods etc

Which pathology and when? *

Please upload any relevant test results you have

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NOK and emergency contact details

Name *

Relationship *

Contact Number *

Occupation *

Privacy & Consent

There are times where we would like to send you a quick message via SMS. Are you happy for us to communicate via SMS? *

YesNo

Specialists on Honeysuckle is a paperless practice. We like to look after the environment as much as possible and therefore prefer to correspond via email. Email correspondence includes: Normal results, appointment letters etc. Are you happy for us to communicate via email? *

YesNo

I consent the information provided is true and correct *

I consent to collection of my personal information for treatment *

Signature *

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