Wide Bay Hospital and Health Service
Public Health Unit
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History or Catch-up Request Form
FAX to 4303 7559
Pages  _______  (Inclusive)

Practice: <Practice>
Person Requesting: <DrName>
Date: <TodaysDate>
Practice Phone: <UsrPhone>
Practice Fax: <UsrFax>
Secure Email: <Secure Email?>
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HISTORY OR CATCH-UP request?: <History OR Catch-up request?>
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ALL requests need the following information:
   Note: Catch up schedules cannot be developed unless all the relevant information is provided.

- Patient details
Re: <PtFullName>
DOB: <PtDoB>
Gender: <PtSex>
Indigenous: <Does patient identify as indigenous?>
Medicare Card: <Does patient have a Medicare card?>
Medicare Card Number: <PtMCNo>   ref no <PtMCLine>     
Address: <PtAddress>
Patient known by another name?:<Patient known by another name?> 
Name also known as:  <Name also known as?>
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For Catch-up Requests:     Attach copy of all immunisation history available.
If applicable, please advise if child medical at-risk, had gestation age <32 weeks, or birth weight <2000g
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Additional information is needed for:
1. Adolescent 10 to 19 years
• Please advise current school year level: <School year level (if applicable)?>   Has left school: <Has left school?>
• Has patient ever had vaccinations through school? <Has patient ever had vaccinations through school?>
               - if yes, name the school: <If yes, name the school>
               - were they given in this current year? <Were they given in this current year?>
2. Overseas catch up        
Country the patient was vaccinated in: <Country the patient was vaccinated in (if other than Australia)?>
Overseas history to be sent - must be a clear copy that can be read once faxed
AIR Immunisation history form [IM013.1609] should be included to assist with catch-up.
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Immunisation list:
<Imm>
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PLEASE FAX YOUR REQUEST TO 4303 7559
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