Pre-Appointment Patient Form

If you are booked for an appointment with us, please submit your details below prior to your appointment.

First Name

Middle Name(s) (if any)

Last Name

Clinic Location

Confirm 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 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?

WARNING - Before submitting your details, please check for the locked padlock symbol in your web browser URL. If you see a locked padlock, the form is secure. Your details will be secured in accordance with our privacy policy.

If instead you see a padlock with a strike through it, or your browser URL says "Not Secure" - the form is not secure. Do not click submit - please notify our staff and complete a printed "WBNM Patient Form.pdf".

Before submitting, please confirm you have checked and your details are all correct:

I confirm my details are correct

Privacy Notice: Your personal information is securely collected for the purpose of registering your details and providing access to your patient portal. We are committed to protecting your privacy and ensuring your data remains confidential in compliance with applicable privacy laws.