Patient Information

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Different Postal Address?

Yes

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Mobile

(###)

###

####

Would you like to receive SMS appointment reminders?

Yes

No

Do you identify as being of Aboriginal and/or Torres Strait Islander origin?

Yes

No

Primary Contact

First Name

Last Name

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Mobile

(###)

###

####

Date

MM

DD

YYYY

Expiry Date

MM

DD

YYYY

Where you referred by your regular GP

Yes

No

Have you been diagnosed with diabetes?

Yes

No

Do you have high blood pressure or currently receiving treatment for high blood pressure?

Yes

No

Do you have high cholesterol or receiving treatment for high cholesterol?

Yes

No

Are you a smoker?

Yes

No

Are you an ex-smoker?

Yes

No

Have you ever been diagnosed with a stroke, ischaemic heart disease or had a heart attack?

Yes

No

Have you had a stent or undergone angioplasty?

Yes

No

Have you undergone coronary artery bypass surgery?

Yes

No

Have you ever been diagnosed with Atrial Fibrillation?

Yes

No

Do you have a Cerebral Aneurysm Clip?

Yes

No

Do you have a Cochlear or Ear Implant?

Yes

No

Do you have a Cardiac Pacemaker/Defibrillator/Wires/pumps/implantable devices?

Yes

No

Have you been a metal worker, welder or had an eye injury caused by metal?

Yes

No

Do you have any other metal implants (ed: sires,screws, plates, joints, devices, stimulators)?

Yes

No

Are you Left or Right handed?

Left

Right