Patient Health Information Request - Adelaide Medical Centre

Non-urgent advice: We are recording all of our patient’s Ethnicity, BMI and Smoking status

This has become very important because these are risk factors for COVID19 and how unwell you may become if you contract the virus. We know that these are also risk factors for other illnesses such as diabetes. Having this information on your medical notes means that we can calculate your risk and then we can initiate further monitoring and support services if you have been confirmed positive for COVID 19. It will also help us deliver high quality care to people who need it most.

Non-urgent advice: Patient Notice

Please complete a separate form for each household member registered with us at Adelaide Medical Centre.

Health Questionnaire

Full Name *

First

Date of Birth *

Last

Home Residence Postcode

Mobile phone number

Ethnicity * Ethnicity

Smoking status

Never smoked tabacco

Ex smoker of tobacco

Current smoker of tobacco

Current weight (if known) any metric

Current height (if known) any metric

If you are human, leave this field blank.