CObH Client Demographic Form - Country & Outback Health

Client Demographic Form

Please complete all information required in the form fields below

Client Demographic Form

Full name (on Medicare Card) *

Date of Birth *

Gender

Phone *

Are there any restrictions regarding how or when we contact you?

Residential Address *
Address Line 1
City
State / Province / Region
Postal Code
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.

Different Postal Address
My postal address is different to my residential addresss

Do you have religious, cultural, language or other special requirements you would like to discuss which could allow Country & Outback Health to provide you with a more appropriate service for your needs?
If yes, your clinician/worker will discuss with you privately

Health Care Card?

Medicare Card Number

Medicare Card Ref Number

Medicare Card Expiry Date

National Disability Insurance Scheme (NDIS) Participant?

Department Veterans Affairs *

Country of Birth *

Do you identify as an Aboriginal or Torres Strait Islander?

Are you currently pregnant or do you have a child under 1 year of age? *

Complete only if not born in Australia

Migration Status:

Humanitarian/Refugee Asylum Seeker:

Period of Residency in Australia (in years):

Language

Main Language spoken: *

Proficiency in English: *

Living Arrangements

Usual accommodation: *

Marital Status: *

Living with: *

Education

Education *

Employment

Employment/Occupation Status: *

Usual Occupation: *

Source of Income: *

Date

Comment