Patient Form | Wide Bay Nuclear Medicine

Patients - if you are booked for an appointment with us, please submit your details below:

Appointment location *

First name *

Middle name(s) (if any)

Last name *

Email *

Are you allergic to anything? *

If yes, please list what you are allergic to:

Do you have diabetes? *

If you have diabetes, what treatment do you receive?

Have you ever had a heart attack? *

If you have had a heart attack, on what date(s) did you have the heart attack(s):

Do you suffer from chest pain/angina? *

Do you use GTN spray or nitrate patches? *

Do you use anginine? *

Do you use isordil? *

Have you ever had heart surgery? *

If you have had heart surgery, on what date(s) did you have surgery:

Have you ever had angioplasty? *

Do you have an irregular heart beat? *

Do you have any medical conditions that you could prevent you from exercising on our bicycle? (e.g. joint replacements, asthma, severe back pain or arthritis) *

If yes, please list what medical condition(s) could prevent you from exercising on our bicycle:

Do you have asthma? *

If yes, have you ever been hospitalised with asthma?

Are you being treated for high blood pressure? *

Are you currently taking any medications? *

If yes, please list ALL medications you are currently taking:

Would you like a copy of our report to be sent to your local doctor? *

If yes, what is the name and medical practice of your local doctor?

Were you unsure about any of these questions? *