Palpitations - {{first name}} {{surname}}

PERSONAL INFORMATION

First Name

Surname

Date of Birth

Email Address

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Medicare Card Number - IRN *

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HEALTH BACKGROUND

Description of palpitations?

Fluttering or rapid heartbeatPounding or thumping in the chestSkipping or irregular heartbeatSlow heartbeat (bradycardia)Palpitations occur suddenly and resolve quicklyPalpitations last for an extended periodOther

Other

Onset and frequency

Occur occasionally (less than once a week)Occur frequently (several times a week)Occur dailyPalpitations started recentlyI have experienced palpitations for a long time

Other

Triggers

Stress or anxietyPhysical exertion or exerciseCaffeine consumption (e.g., coffee, tea, energy drinks)Alcohol consumptionSmoking or use of recreational drugsCertain medications

Other

Associated Symptoms

Dizziness or lightheadednessFainting or near-fainting episodesShortness of breathChest pain or discomfortFatigue or weaknessSweatingNausea

Other

Timing and Patterns

Occur at restOccur during physical activityOccur mostly at night or while lying downOccur after eating or drinking

Other

Medical History

History of heart disease (e.g., arrhythmia, heart attack)High blood pressureThyroid problems (e.g., hyperthyroidism)Anxiety or panic disordersAnemia or low blood countElectrolyte imbalancesUse of a pacemaker or other cardiac device

Other

Previous Assessments

I have had an ECG (electrocardiogram) or heart monitoringI have been diagnosed with an arrhythmia or heart rhythm disorderI am currently taking medications for heart rhythmI have not had any previous evaluations for palpitations

Other

Lifestyle

I have a high-stress lifestyleI engage in regular physical activityI follow a healthy dietI have difficulty maintaining a healthy sleep schedule

Other

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DECLARATION

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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