Sore Throat - {{first name}} {{surname}}

General Information

First Name

Surname

Date of Birth

Email Address

Medicare Card Number - IRN *

Home Phone

Mobile Phone

Home Address

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

Sore throat

When did you start having a sore throat?

Less than 24 hours1-3 days4-7 daysMore than 7 days

Do you have any of the following symptoms associated with your sore throat?

Fever or chillsCoughDifficulty swallowing or painful swallowingSwollen lymph nodes (neck tenderness)Hoarseness or loss of voiceRunny or stuffy noseRashWhite patches or pus on the tonsilsHeadacheNausea or vomitingBody achesNo additional symptoms

Have you experienced any of the following recently?

Exposure to someone with a known viral or bacterial infection (e.g., strep throat, flu)Recent cold or respiratory infectionAllergies or sinus issuesAcid reflux or GORDSmoking or exposure to secondhand smokeRecent dental issues or oral surgeryNone of the above

Medical Background

Please list any medications you are currently taking.

List al your medications (including Name, Dose and Frequency).

Please list any allergies.

Allergy

Please list any surgeries

Surgery

Do you consume alcohol?

NeverDailyOnce a weekOnce a monthOnce a year

Do you smoke?

YesNoI used to smoke

Do you use recreational drugs?

NoI have previously usedI currently use

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. *

Signature

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Date

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