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
Invalid Input

 

Medical Information

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

Referring Doctor
Invalid Input

Suburb
Invalid Input

Usual GP
Invalid Input

Suburb
Invalid Input

Other Interested Parties
Invalid Input

Suburb
Invalid Input

Follow Up Date
Invalid Input

 

Medical History

Height*
Please enter your height.

Weight*
Please enter your weight.

Have you been told of a problem with your arteries or veins?*
Please select Yes or No.

What was it?
Invalid Input

Have you been diagnosed with or treated high blood pressure / hypertension?*
Please select Yes or No.

Do you have elevated cholesterol?*
Please select Yes or No.

Have you been told you have a problem with your lower back or hips?*
Please select Yes or No.

Have you received chemotherapy or radiotherapy?*
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.

Have you ever had a pulmonary embolism?*
Please select Yes or No.

Have you ever had leg ulcers?*
Please select Yes or No.

Do you have varicose veins?*
Please select Yes or No.

Have you ever had a stroke?*
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?
Invalid Input

Have you ever had deep vein thrombosis?*
Please enter Yes or No.

In which vein and when?
Invalid Input

 

Current Symptoms (experienced in the last 3 months)

Do you experience dizziness?*
Please select Yes or No.

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

Have you been experiencing leg pain at rest?*
Please select Yes or No.

Does the pain increase when you stand up for a long time?*
Please select Yes or No.

Do your feet and toes get cold or painful when you lie down?*
Please select Yes or No.

 

Have you had any of the following tests performed?

An injection or operation to a vein or artery?*
Please select Yes or No.

Please provide details
Invalid Input

A previous test or scan done on your arteries or veins?*
Please select Yes or No.

Please provide details
Invalid Input

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

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

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