Fax: 08 6313 2244

OneCare Cardiology

New Patients

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

New Patients

If this is your first visit, please complete the patient questionnaire before requesting your appointment.

Form 1: Patient Questionnaire
Form 2: Appointment Request Form

Complete Form 1

Next Step

After completing the patient questionnaire, please complete the appointment request form below.

Complete Form 2

Existing Patients

If you are a existing patient, please fill the form 2.

Form 2: Appointment Request Form

Complete Form 2

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.

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

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

Have you had any history with cardiac disease/ issues?

Yes No

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

Yes No

Have you had any other important medical conditions?

Yes No

Do you have the following?

4 Previous Cardiology History

Have you previously seen a cardiologist?

Yes No

Are you able to bring your previous records and reports?

Yes No

I understand that failure to disclose that I have previously undergone a transthoracic echocardiogram (MBS item 55126) or a stress echocardiogram (MBS item 55141) may make me ineligible for bulk billing. In such a case, I understand that I may be required to pay the applicable scheduled fee for these services.

5 Medicare, Pension, DVA & Private Health Insurance

Do you have a valid Medicare Card?

Yes No

Are you a Pension Card Holder?

Yes No

Are you a DVA Card Holder?

Yes No

Do you have Private Health Insurance?

Yes No

6 Current Symptoms

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

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

Yes No

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

Yes No

Have you had any of the following episodes?

7 Lifestyle

Do you exercise regularly?

Yes No

Do/ did you smoke cigarettes?

Yes No

Do/ did you drink alcohol?

Yes No Social only

Do/ did you drink coffee?

Yes No

8 Medications

Are you taking any regular medications?

Yes No

9 Additional Information

Any other comments:

Optional. Maximum 2,000 characters.

10 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 Patients

New Patients

Next Step

Existing Patients

Need assistance?

Please review the following fields

1 Patient Details

2 Reason for Cardiology Consultation

3 Cardiac and Medical History

4 Previous Cardiology History

5 Medicare, Pension, DVA & Private Health Insurance

6 Current Symptoms

7 Lifestyle

8 Medications

9 Additional Information

10 Patient Declaration

Ready to take the next step?