Personal Information

Title*
Please select your title.

First Name*
Please enter your first name.

Middle Initial

Last Name*
Please enter your last name.

Date of Birth*
Please enter your date of birth

Email*
Please enter your email address.

Postal Address*
Please enter your postal address.

Suburb*
Please enter your suburb.

State*
Please select a state.

Postcode*
Please enter your postcode.

 

Emergency/Next of Kin Information

First Name*
Please enter your emergency contact's first name.

Last Name*
Please enter your emergency contact's last name.

Relationship*
Please enter your relationship with your emergency contact.

Phone 1*
Please enter your emergency contact's telephone number.

Phone 2
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Medication Information

Medications*
Please list all the medications (including herbal medicines) you are taking.

Referring Doctor
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Suburb
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Usual GP
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Suburb
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Other Interested Parties
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Suburb
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Follow Up Date
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Medical Illnesses

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Specify
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Medical History

Height*
Please enter your height.

Weight*
Please enter your weight.

Have you received chemotherapy or radiotherapy?*
Please select Yes or No.

Have you had a heart attack (myocardial infarction)?*
Please select Yes or No.

Have you been diagnosed with coronary artery disease/heart disease/angina?*
Please select Yes or No.

Have you been diagnosed with or do you take medication for high blood pressure / hypertension?*
Please select Yes or No.

Have you been diagnosed with or do you take medication for elevated cholesterol?*
Please select Yes or No.

Have you been diagnosed with Diabetes?*
Please select Yes or No.

Do you currently smoke?*
Please select Yes or No.

Are you an ex-smoker?*
Please select Yes or No.

Has anyone in your family had heart disease or a heart attack?*
Please select Yes or No.

If so, who was it and at what age were they diagnosed?
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Current Symptoms (experienced in the last 3 months)

Have you been experiencing chest pain/chest discomfort/heaviness?*
Please enter Yes or No

If yes, how often do you experience chest pain/chest discomfort/heaviness?
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When does the pain occur?
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How long does the pain last usually?
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Do you do have difficulty performing strenuous activities?*
Please select Yes or No.

Do you get short of breath?*
Please select Yes or No.

Do you get swelling of the ankles (oedema)?*
Please select Yes or No.

Do you experience palpitations / missed beats / extra beats / racing heart?*
Please select Yes or No.

 

Have you had any of the following tests performed?

Exercise stress test, Stress Echo, Echocardiogram (ultrasound of the heart) or ECG?*
Please select Yes or No

If yes, how long ago?
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Coronary Angiogram (Cardiac catheterisation)?*
Please select Yes or No.

Angioplasty (PTCA) or had stent/s inserted?*
Please select Yes or No.

Coronary artery bypass surgery (CABG)?*
Please select Yes or No.

Heart Valve Surgery?*
Please select Yes or No.

Do you have a Pacemaker/ other medical devices?*
Please select Yes or No

If so, what type?
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Any other heart surgery not listed above*
Please select Yes or No.

Specify
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Do you snore?*
Please select Yes or No.

Have you had a Sleep Study?*
Please select Yes or No.

Has anyone seen you not breathing in sleep?*
Please select Yes or No.

Are you on CPAP therapy (machine used at night)?*
Please select Yes or No.

Do you have daytime sleepiness?*
Please select Yes or No.

Please tick the box below *
Please tick the box to continue.