Sunshine Coast Vascular Health Research Register

Thank you for submitting your details to the Sunshine Coast Cardiovascular Health Research Register!

Please complete all the questions as accurately as possible.
We will only use your contact details to provide you with information about your condition(s) and to inform you of research projects that may be of interest to you. We will only contact you about research projects that have been approved by a Hospital or University Research Ethics Committee.
Your contact details and personal health information will remain strictly confidential. We will not give your details to anyone under any circumstances.
If you would like to have your details removed from the register, or if you have any queries, please contact us by email: vasoactive@usc.edu.au

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* 1. Your contact details

Full name

Address

Address 2

City/Town

State

Post Code

Country (if not Australia)

Email Address

Phone Number

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* 2. Are you male or female?

Male

Female

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* 3. In what year were you born? (enter 4-digit birth year; for example, 1976)

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* 4. Have you ever been diagnosed with any of these conditions?

	Yes	No	Not sure
Heart condition (including heart failure, or heart attack)	Heart condition (including heart failure, or heart attack) Yes	Heart condition (including heart failure, or heart attack) No	Heart condition (including heart failure, or heart attack) Not sure
Stroke	Stroke Yes	Stroke No	Stroke Not sure
Peripheral Vascular Disease (poor leg circulation)	Peripheral Vascular Disease (poor leg circulation) Yes	Peripheral Vascular Disease (poor leg circulation) No	Peripheral Vascular Disease (poor leg circulation) Not sure
Hypertension (high blood pressure)	Hypertension (high blood pressure) Yes	Hypertension (high blood pressure) No	Hypertension (high blood pressure) Not sure
Diabetes (high blood sugar)	Diabetes (high blood sugar) Yes	Diabetes (high blood sugar) No	Diabetes (high blood sugar) Not sure
Abdominal Aortic Aneurysm (AAA, dilation of the aorta)	Abdominal Aortic Aneurysm (AAA, dilation of the aorta) Yes	Abdominal Aortic Aneurysm (AAA, dilation of the aorta) No	Abdominal Aortic Aneurysm (AAA, dilation of the aorta) Not sure
Venous condition (including venous ulcers, or varicose veins)	Venous condition (including venous ulcers, or varicose veins) Yes	Venous condition (including venous ulcers, or varicose veins) No	Venous condition (including venous ulcers, or varicose veins) Not sure

Other? (please specify)

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* 5. Please tell us about your health habits and risk factors.

	Yes	No	Not sure
Do you smoke cigarettes, or have you in the past?	Do you smoke cigarettes, or have you in the past? Yes	Do you smoke cigarettes, or have you in the past? No	Do you smoke cigarettes, or have you in the past? Not sure
Have you ever been told that your blood cholesterol is high?	Have you ever been told that your blood cholesterol is high? Yes	Have you ever been told that your blood cholesterol is high? No	Have you ever been told that your blood cholesterol is high? Not sure
Do you consider yourself to be physically active?	Do you consider yourself to be physically active? Yes	Do you consider yourself to be physically active? No	Do you consider yourself to be physically active? Not sure
Do you eat a healthy diet?	Do you eat a healthy diet? Yes	Do you eat a healthy diet? No	Do you eat a healthy diet? Not sure
Has any member of your immediate family had a heart attack or stroke (including your parents, siblings or children)?	Has any member of your immediate family had a heart attack or stroke (including your parents, siblings or children)? Yes	Has any member of your immediate family had a heart attack or stroke (including your parents, siblings or children)? No	Has any member of your immediate family had a heart attack or stroke (including your parents, siblings or children)? Not sure

Other? (please specify)

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* 6. Please list any medications or supplements (e.g. fish oils) that you are prescribed or take regularly

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* 7. Are you interested in hearing about new research studies that you might be eligible to participate in?

Yes, I would like to be contacted about new research studies.

No, I do not want to contacted about new research studies.

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* 8. Are you interested in receiving general information about your health condition(s)?

Yes, I would like to receive general health information.

No, I do not want to receive general health information.

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* 9. What is your preferred contact method?

postal mail

telephone