Contact Information

First Name *

Surname *

Email *

Date of birth *

Occupation

Usual GP *

Emergency Contact Name *

Emergency Contact Number *

Weight (kg)

Height (cm)

Respiratory History

Do you, or have you previously smoked? *

YesNo

How many cigarettes do/ did you smoke?

For how many years?

If so: How long ago did you quit?

Have you had any lung function testing done in the past 5 years? *

YesNo

Where and when did you have the lung function test?

Have you been to hospital in the past 5 years due to respiratory issues? *

YesNo

Which hospital and what date did you attend?

Do you, or your GP have discharge summaries?

YesNo

If yes please provide your discharge summary

Have you had any medical imaging of the chest, head and sinuses in the past 5 years? *

YesNo

Example: X-rays, CT scans, MRI

Where and when were they done? (approximately)

Have you had any of the following pathology tests done in the last 5 years? *

SputumNasal swabsNo

Have you had blood test(s) done in the last 5 years? *

YesNo

Please provide name of provider and dates(s) performedProvider example: S&N, QML, 4Cyte, GP

Have you been diagnosed with respiratory issues in the past? *

YesNo

What was the diagnosis?

Do you see other Specialists? *

YesNo

Provide details (name, location)

Medical History

Any further details or other medical condition than listed above?

Do you have any known allergies?

Alcohol intake (number per day/ week/ month)

Medications

Medication (prescribed/ non-prescribed currently being taken)

Dosage (include if taken in morning or evening)

Work History

If relevant, please let us know if you have worked in an environment with asbestos exposure or prolonged dust exposure Please be as detailed as possible

Save and Complete Later

This form will be submitted via email to Thoracic and Sleep Group Queensland. A copy will also be sent to the email address provided above.