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Fax: 08 6313 2244

OneCare Cardiology

New Patient’s Questionnaire

Complete the OneCare Cardiology new patient questionnaire before your specialist appointment.

Please complete this questionnaire before your appointment with the specialist. Your responses will help our cardiology team understand your symptoms, medical history and current medications.

This form usually takes approximately 5 to 10 minutes to complete.

Need assistance?

Phone:
08 6313 2232

Fax:
08 6313 2244

Address:
136 Main Street,
Osborne Park, WA 6017

Privacy information: This questionnaire contains health information and is submitted using encrypted HTTPS transport. Email is not a clinical record system. Call 08 6313 2232 if you would prefer to discuss another submission method.

1 Patient Details

Title

Family Name

Given Name

Gender

Date of Birth

Job Title

Form Completion Date

2 Reason for Cardiology Consultation

1. What is your main symptom/ reason (main concern) that brought you here to see a cardiologist?

Maximum 2,000 characters.

3 Cardiac and Medical History

2. Have you had any history with cardiac disease/ issues?

Yes No

3. Do you have any family history with cardiac disease/ issues?

Yes No

4. Have you had any other important medical conditions?

Yes No

5. Do you have the following?

4 Current Symptoms

6. Do you have any of the following symptoms during your daily life activities?

Chest Pain Chest tightness Chest compression Chest Discomfort None of the above

7. Do you have shortness of breath (SOB) in your daily life activities?

Yes No

8. Do you have chest pain or shortness of breath when you are going uphill or upstairs?

Yes No

9. Have you had any of the following episodes?

5 Lifestyle

10. Do you exercise regularly?

Yes No

11. Do/ did you smoke cigarettes?

Yes No

12. Do/ did you drink alcohol?

Yes No Social only

13. Do/ did you drink coffee?

Yes No

6 Medications

14. Are you taking any regular medications?

Yes No

7 Additional Information

15. Any other comments:

Optional. Maximum 2,000 characters.

8 Patient Declaration

I confirm that the information I have provided is accurate to the best of my knowledge.

Patient Full Name

Type your full name as your electronic signature

Signature Date

Please review your answers before submitting. Contact OneCare Cardiology on 08 6313 2232 if you need assistance.

Appointments

Ready to take the next step?

Request a cardiology appointment or upload your referral for the clinic team to review. Urgent referrals should be discussed with the clinic directly.

Request an Appointment Upload Referral

New Patient’s Questionnaire

Need assistance?

Please review the following fields

1 Patient Details

2 Reason for Cardiology Consultation

3 Cardiac and Medical History

4 Current Symptoms

5 Lifestyle

6 Medications

7 Additional Information

8 Patient Declaration

Ready to take the next step?