Dr Moses Abe Patient Registration Name First Name Surname Address Street Address City State Post Code Contact Number MobileEmail DOB MM slash DD slash YYYY AgeYearsAre you of Aboriginal or TSI descent Yes No Do you have a partner ? Yes No Please enter your Emergency Contact/Next of Kin Partner’s DetailsName Relationship Partner's DOB MM slash DD slash YYYY Contact Mobile Number Your Medicare Number Your Partner's Medicare Number Patient Number on Medicare Card(# next to name) Do you have private insurance? Yes No Name of Fund and level Patient's Reference Number Local Doctor’s (GP) Name Telephone Number GP Address Street Address City State Postal Code Number of previous pregnancies Number of children Average Menstrual cycle length in days ( eg 27 - 35 days ) Have you been trying to achieve pregnancy? Yes No If so, how long? Have you ever had an open abdominal or pelvic surgery? ( including Caeserean ) Yes No Briefly StateDo you have any known allergies ? Yes No Could you tell us more about your allergies? Are you taking anticoagulants ( Aspirin, Plavix, Warfarin )? Yes No Do you smoke cigarettes ? Yes No How many per day? Your weight? kgYour height cmHave you had any serious Medical Illness ? Yes No briefly state