Client Demographic Form
Full name (on Medicare Card)
*
Preferred Name
Date of Birth
*
Gender
Pronoun
Mobile
*
Phone
Prefer contact by email
Yes
No
Prefer contact by SMS
Yes
No
Residential Address
*
Street address
*
Street address line 2
City
*
State
*
Please select
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
*
Country
Please select
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombi
Comoros
Congo (Brazzaville)
Congo
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
This service is only available within South Australia. Check our services page for specific locations. Or contact Head to Health directly on 1800 595 212 or visit website www.headtohealth.gov.au for alternative services in their area.
My postal address is different to my residential addresss
Postal Address
*
Street address
*
Street address line 2
City
*
State
*
Please select
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
*
Country
Please select
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombi
Comoros
Congo (Brazzaville)
Congo
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
This service is only available within South Australia. Check our services page for specific locations. Or contact Head to Health directly on 1800 595 212 or visit website www.headtohealth.gov.au for alternative services in their area.
Are there any restrictions regarding how or when we contact you?
Health Care Card?
Yes
No
Age Care Package?
Yes
No
National Disability Insurance Scheme (NDIS) Participant?
Yes
No
Medicare Card Number
Medicare Card Ref Number
Medicare Card Expiry Date
Department Veterans Affairs
*
Yes
No
Department Veterans Affairs cont.
Gold
White
Country of Birth
*
Do you identify as an Aboriginal or Torres Strait Islander?
No
Aboriginal
Torres Strait Islander
Both
Are you or your partner currently pregnant or do you have a child under 1 year of age?
Yes
No
Comments
Complete only if not born in Australia
Migration Status
Migrant
Other
Humanitarian
Refugee
Asylum Seeker
Period of Residency in Australia (in years)
Language
Main Language spoken
*
Proficiency in English
*
Not applicable (under 5)
English only
Very well
Well
Not well
Not at all
Interpreter required
Living Arrangements
Usual accommodation
*
Private residence
Boarding Housing
Aged Care
Non-conventional accommodation
Emergency accommodation
Other supported accommodation
Sleeping rough/Homeless
Other
Please specify
Marital Status
*
Married
De-Facto
Widowed
Divorced/Separated
Never Married
Living with
*
Spouse
De-Facto
Children
Alone
Sibling/s
Parent/s
Foster Parent
Friends
Other
Please specify
Education
Education
*
Pre-primary
Primary
Year 8 or equivalent
Year 9 or equivalent
Year 10 or equivalent
Year 11 or equivalent
Year 12 or equivalent
Certificate
Advanced diploma
Graduate Diploma or Graduate Certificate
Bachelor degree
Employment
Employment/Occupation Status
*
Full time
Part time
Casual
Unemployed
Homemaker
Student
Child not at school
Retired
Carer
Volunteer
Not in the labour force
Other
Usual Occupation
*
Source of Income
*
N/A aged less than 16
Paid employment
Disability Support Pension
Newstart Payment
Compensation payment (e.g. Workover)
Pension or Benefit
Nil Income
Other (e.g. Superannuation, Investments)
Date
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