PATIENT DETAILS

Please complete all of the sections of this page with your personal details.

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* 1. Full name:

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* 2. Date of birth

Date

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* 3. Gender:

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* 4. Address:

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* 5. Phone number:

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* 6. Email address:

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* 7. Height (cm):

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* 8. Weight (kg):

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* 9. What is your ethnicity? (Please select all that apply.)

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* 10. Please give the name, address and contact details of your nominated doctor or GP

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* 11. I consent to undergoing the Cardiogenics cardiac screening tests

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* 12. Have you ever been told that you have a heart condition (including a 'murmur')?

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* 13. Have you had a brother, sister, parent, grandparent or cousin (under the age of 40) who died suddenly and unexpectedly due to a heart condition or for which no cause was found? (Including drowning or sudden infant death)

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* 14. Does your immediate family have a history of heart disease?

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* 15. Have you ever blacked out or lost consciousness at any time of your life and for no obvious reason?

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* 16. Do you ever feel dizzy or get light headed during or after exercise?

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* 17. Have you ever experienced rapid or irregular heartbeats?

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* 18. Do you experience a shortness of breath when walking or doing normal activities?

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* 19. Do you feel that you get more breathless than your peers or teammates?

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* 20. Have you ever experienced pain, tightness or heaviness in your chest?

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* 21. Do you take any drugs or medication? (Including recreational drugs)

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* 22. What sports or activities do you do?

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