Cough - {{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

Cough History

New cough

Persistent cough for more than 3 weeks

Recurrent episodes of cough

What is the cough's characteristics?

Dry cough

Productive (wet) cough

Blood in cough (haemoptysis)

Barking cough

Whoop sounding cough

Any associated symptoms?

Fever/chills

Night sweats

Shortness of breath

Chest pain

Sore throat, runny nose, watery eyes

Nausea/vomiting

What triggers the cough?

Exposure to cold air

Exacerbated by physical activity

Lying flat

Worse at night or mornings

Exposure to irritants/smoke/inhalants

Recent contact with an unwell individual

Medical Background

Please list all your medical conditions.

Please list any medications you are currently taking

Medications (Include Name, Dose, Frequency)

Please list any allergies

Allergy

Severity

Please list any surgeries

Surgery

Date

Do you smoke?

YesNoI used to smoke

Do you use recreational drugs?

NoI have previously usedI currently use

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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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