IF THE CHEST PAIN HAS COME ON SUDDENLY, CALL 000 OR PRESENT TO YOUR NEAREST EMERGENCY DEPARTMENT.

Chest Pain - {{first name}} {{surname}}

General Information

First Name

Surname

Date of Birth

Email Address

Home Phone

Mobile Phone

Home Address

Medicare Card Number - IRN *

How did you find out about us?

Emergency Contact Information

Emergency contact

Phone

Emergency contact’s relationship to you

Work Information

Current work status

EmployedRetiredNot workingLight Duty

Occupation

Characteristics of the pain

Sharp or stabbing pain

Dull or aching pain

Pressure or tightness

Burning sensation

Radiating pain (e.g. to arms, neck, jaw, back etc.)

Pain that comes and goes

Constant pain

When did the pain start?

Sudden onset

Gradual onset

Pain triggered by physical activity

Pain occurring at rest

What is the duration and timing of the pain

Lasts seconds to minutes

Lasts hours or longer

Pain occurs primarily during the day

Pain occurs mainly at night

What triggers the pain?

Exertion or physical activity

Emotional stress

Meals

Breathing in deeply

Cough

Body position (e.g. leaning forwards improves the pain etc.)

What improves the pain?

Resting

Medications (e.g. GTN spray)

Changing body position

Any associated symptoms?

Shortness of breath

Dizziness or lightheadedness

Nausea or vomiting

Sweating

Palpitations

Fatigue

Coughing

Fever/chills

Medical Background

Please list all your medical conditions (High Blood Pressure, Asthma, Diabetes etc.)

Please list any medications you are currently taking.

Medications (Include Name, Dose and Frequency)

Please list any allergies.

Allergy

Please list any surgeries.

Surgery

Do you smoke?

YesNoI used to smoke

Do you use recreational drugs?

NoI have previously usedI currently use

Please upload any additional information.

Browse

Consent

I confirm that the above information I have provided is true, complete and accurate. I agree to be contacted by a health professional via telehealth. *

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