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Form library · MED-002

GP medical history questionnaire

Example only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. This example has not had a separate legal review.

Rules differ by state; check yours.

Australian GP practices asking about conditions, medicines and allergies.

A short history the practice reviews. It asks about conditions, medicines and allergies. It is not a diagnosis and it is not a government health record.

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GP medical history questionnaire

Example only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. This example has not had a separate legal review.

Example only. Fictional practice: Example Medical Practice, Subiaco. A yes answer does not decide treatment.

Tell us if any of these apply
Are you pregnant?
Do you take a medicine that affects bleeding?

Privacy: Example Medical Practice collects this information to provide your care. We may share it with the people who treat you. Read our privacy policy at example.com/privacy. Example only: the practice must write its own collection notice. See GEN-002.

Fields

  • Conditions

    Heart, diabetes and asthma, plus a free-text other.

  • Medicines

    What they take now, in their own words.

  • Allergies

    Reactions, in their own words.

  • Pregnancy

    Yes or no.

  • Bleeding

    Whether they take a medicine that affects bleeding.

  • Health information

    A tick. The practice collects the health information on the form for care.

  • Collection notice

    A line the practice writes before anyone uses the form.

Questions

Who should check the wording?

The practice, against its own rules and the health-records law in its state.

Does a yes answer decide treatment?

No. It tells the practice to read the answer. The form does not decide treatment.

About these templates

These templates are examples only, to help you get started. They are general information, not legal, medical, clinical or professional advice, and they may not suit your business, your profession or your state or territory.

Before you use any template, you must review and adapt it, and have it checked where needed, so it fits your services, your professional body's rules, privacy and health records laws, and the law where you operate. This matters most for consent, waiver, privacy and minors' forms. You are responsible for the forms you use and the information you collect.

To the extent the law allows, nopen gives no warranty that the templates are complete, current or fit for any purpose, and is not liable for loss arising from their use. Nothing here excludes, restricts or modifies any right or remedy you have under the Australian Consumer Law that cannot lawfully be excluded.

The templates are not endorsed by or connected with any government agency, including Services Australia, Medicare or the NDIA. Do not add government logos, the Commonwealth Coat of Arms or other official marks to them. Fields that refer to government numbers (such as a Medicare card number) are labels only.

Example only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. This example has not had a separate legal review.