Nausea or Vomiting - {{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

Vomiting history

Sudden onset

Recurrent episodes

Persistent (lasting more than 24 hours)

Blood in vomit (haematemesis)

Yellow or green vomit

Undigested food in vomit

What are you seeing us about?

Any associated symptoms?

Nausea

Abdominal pain

Fever or chills

Diarrhoea

Dizziness or lightheadedness

Headache

Fatigue or weakness

Dry mouth, reduced urine output

What are the triggers for you vomiting?

Occurs after eating

Occurs after drinking fluids

Occurs in the mornings

Occurs after physical activity

Occurs with headaches

Occurs with certain scents or smells

Occurs with motion (e.g. car or sea travel)

Any recent exposure to the following?

Uncooked or spoiled foods?

Contact with someone with similar symptoms?

Recent travel to a new environment?

Recent illness?

Pregnancy? (females)

Stressed or anxious about something?

Medical Background

Please list all your medical conditions (e.g. 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. *

Signature

Draw signature|Type signatureClear

Date