Personal Information

Any personal information you share in this form will be stored securely and kept strictly confidential in accordance with Australian privacy laws and regulations.

First name *

Surname *

Address *

Street address *

Suburb *

State *

Postcode *

Date of birth *

Age:

Gender at birth *

MaleFemaleOtherPrefer not to say

Medical Information

Name of your GP

I don't have a regular GP

Name of your GP Practice:

Health History

Based on the health information you've previously shared with us, there may be a cardiovascular clinical trial suitable for you that is currently enrolling participants. To confirm whether this trial is a good fit for you, we just need a few more details about your health history. Some of these questions may feel familiar, and we appreciate your patience in answering them again — it helps us make sure we have everything we need to assess your eligibility accurately.

Have you had any of the following? *

Heart AttackStroke or Transient Ischaemic AttackStent (a small tube inserted to open a blocked artery) or Coronary RevascularisationCoronary Artery Bypass Graft (CABG)Angiogram (a procedure where dye is used to check blood flow into your heart)Coronary Artery Calcium ScoreCholesterol and or Lp(a) tested in the last yearNone of the aboveUnsure

Where was your angiogram done?

What was your calcium score result (if known)?

Where was your calcium score done?

Which type of diabetes have you been diagnosed with? *

Type 1Type 2Unsure

Are you taking any of these medications? *

High blood pressure medicationCholesterol lowering medication (ie. a statin)Diabetes medication (ie. insulin, etc.)I'm not taking any of these medicationsUnsure

Have you been diagnosed with cancer(s) in the last five years? *

YesNoUnsure

What type of cancer(s) have you been diagnosed with in the last five years? *

Do you have a planned cardiac surgery/procedure scheduled? *

YesNoUnsure

Are you currently receiving treatment for a significant medical condition (ie. major infection, chemotherapy, etc.) *

YesNoUnsure

Please specify:

Do you have a parent or sibling that has had a heart attack or stroke before the age of 55 (if male) or before the age of 65 (if female)?

YesNoUnsure

Estimated height in centimetres

Estimated weight in kilograms

BMI

Consent

I have read and agree to the Clinitrials Privacy Policy. *

I consent to Clinitrials contacting my GP to obtain results for: cholesterol, Lp(a), calcium score and or angiogram results as applicable. *

YesNo

By signing below, I confirm the above information I have provided is true, complete and accurate to the best of my ability.

Signature *

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Date *

We thank you for completing the study intake form, your information will stored securely in our system and we will be in touch with next steps.

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Internal Use Only: Medical Enrolment Declaration

I confirm this patient is suitable for Lp(a) screening, based on the information provided and any relevant medical records reviewed.

Doctor Signature

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Doctor Name

Date