Pre-Admission Form  
 
 


Please complete this form prior to your admission.

Page 1 of 7 		 
  Admission details  
 
Which hospital are you being admitted to
Date of admission      Time of admission      Admitting Doctor
Have you been a patient at Essendon Private Hospital before      Yes    No   when (date)  
Have you been a patient at any hospital in the last 7 days?     Yes    No   where  
Are you a day patient or staying overnight?          Day    Overnight     Estimated length of stay    days
 
  Personal Details  
  Title      Surname         Previous surname (if applicable)     
  Given names        Preferred name    
  Address       Suburb    
  State        Postcode        Email address    
  Mobile phone     Home phone    Work phone    
  Date of birth     Age     Sex:     Male        Female    
  Employment:   Child        Employed        Home duties         Retired        Occupation    
  Marital Status:    Married        Defacto        Single        Widowed        Divorced    
  Country of birth        Are you a permamnent resident of Australia    Yes    No  
  Are you of Aboriginal / Torres Strait Islander descent?   No    Yes, Aboriginal   Yes, TSI    Yes, both  
  Religion        Main languages spoken at home    
  Person to contact (Next of kin)  
  Title      Name         Relationship to patient     
  Address       Suburb    
  State        Postcode    
  Mobile phone     Home phone    Work phone    
  Will this person be collecting you after your stay?   Yes    No (if no, please provide the details of this person below)
  Name     Mobile phone    Home phone