Full Name * Date of Birth * Address * Phone * Email * Next of Kin Next of Kin Contact * Relationship Medicare Card no Aged Pension Card Healthcare Card no DVA No Health Insurer Member no Family Doctor * Medical History Symptoms Risk Factor Profile Chest pain *YesNo Hypertension *YesNo Shortness of Breath *YesNo Diabetes *YesNo Palpitations (heart pounding) *YesNo High Cholesterol *YesNo Blackout/Fainting * YesNo Smoker/Ex-Smoker/Non-Smoker * YesNo Dizziness * YesNo Family History * YesNo Leg Swelling * YesNo Sleep Apnoea * YesNo Allergy to medications *YesNo Known heart condition * YesNo Height Weight Medications * Referrals: If your local doctor has referred you, these referrals normally last 12 months. After 12 months you will need to get a new referral for Medicare purposes. If another specialist has referred you, Medicare will only recognise the referral for 3 months and it is advisable that you obtain a referral from your local doctor for your next visit. All new patients are required to sign the consent I consent to the handling of my information by this practice for the purpose of my health management. I understand this could involve disclosure to other doctors, specialists and other involved in my healthcare. I give consent to Dr Rayoo to obtain any past medical records necessary to my care. This clinic uses i-scribe AI during consultations. Signed Date
