Patient Questionnaire

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Patient Questionnaire

Five Star Reviews

Patient Questionnaire

PQS

Step 1 of 5

1. We do not see children under 8 years .......................................... 2. This standalone appointment does NOT mean that the Nassau Clinic has now become your registered GP. If you do not already have your own GP you can find one at https://www.icgp.ie/go/find_a_gp

Given that Nassau Clinic or Dr Liam REGAN is NOT your GP - who is your Doctor?

What is the address of your Doctor?

Have you already been given your appointment time?(Required)

Yes

Before completing this patient questionnaire, you must first have been given an appointment time by either (a) booking online via www.Nassau.ie/book or (b) by telephoning the clinic on 015242848

Date of Birth(Required)

Sex(Required)

Male

Female

Other

Are you pregnant(Required)

Yes

Have you any concerns that you might be pregnant(Required)

Yes

Are you breastfeeding(Required)

Yes

Name(Required)

First Last

Phone(Required)

Address Search (in IRELAND) (Required)

Hidden

Admin Address Control

Show Address Form

Address (if visiting give address of HOTEL or AirBnB or Student Accommodation)(Required)

Address Line 1 Address Line 2 Town or City County Eircode

You MUST arrive 5 minutes BEFORE your appointment, If you are late the Doctor will NOT meet you. Do you accept this(Required)

Yes

Main Reason for Medical Consultation (Choose Only One)(Required)

UTI

Sexual Health

Ear

Eye

Stomach - Gastrointestinal

Respiratory, Flu, Cough

Skin Condition

Covid-19

Prescription Renewal

Other Reason not listed

Describe the Other Reason(Required)

Which Ear(Required)

Left

Right

Which one of the following best describes your sexual relationships(Required)

Exclusively with WOMEN

Exclusively with MEN

With both WOMEN and MEN

Do you have any concerns that RIGHT NOW you MAY have Monkey Pox(Required)

Yes

Do you have any concerns that RIGHT NOW you MAY have Monkey Pox(Required)

Yes

Do you have any concerns that RIGHT NOW you MAY have Monkey Pox(Required)

Yes

Do you take PrEP medication(Required)

Yes

Do you take Gym supplements such as CREATINE(Required)

Yes

What is your HIV Status(Required)

Never had a HIV test before

Negative when last tested

Positive

Positive Undetectable

Recently tested but awaiting result

Are you vaccinated against Hepatitis A(Required)

YES

Are you vaccinated against Hepatitis B(Required)

YES

Are you vaccinated against HPV Human Papillomavirus(Required)

YES

List the medication, Milligram & Number (Dosage) Required

Preferred Pharmacy(Required)

If we need to issue a prescription for medication, please name your preferred pharmacy and address

COVID 19 - Your vaccination status(Required)

Not Vaccinated

One Vaccination

Two Vaccinations

Vaccination + Booster

Have you any concerns about COVID(Required)

Yes

Have you been outside Ireland in the last 2 weeks(Required)

Yes

TODAY have you already completed a rapid COVID Test(Required)

Yes

COVID19- Did your ever test positive using Antigen or PCR(Required)

Yes

COVID19 - TODAY did you test positive(Required)

Yes

When date did you test positive?(Required)

Did you ever attend a Medical Clinic / Doctor in Ireland(Required)

Yes

What is the name of that Medical Clinic / Doctor(Required)

In the last month did you consult with a Doctor or visit an Emergency Dept. (ED) or stay Overnight in a Hospital(Required)

Yes

Name the Doctor / ED / Hospital & the reason for your visit(Required)

Are you ALLERGIC to any medication(Required)

Yes

Allergic to : - List the medication(Required)

Do you take any regular medication(Required)

Yes

Regular Medication - please list(Required)

Are you immunocompromised(Required)

Yes

Can you provide some additional information(Required)

Are you a smoker / or have you ever been a smoker(Required)

Yes

How many cigarettes per day(Required)

Do you have Asthma(Required)

Yes

Is your LIVER (hepatic) impaired(Required)

Yes

Are your KIDNEYS (renal) impaired(Required)

Yes

Did you ever attend this clinic with Dr. Liam REGAN before(Required)

Yes

Please tick the boxes that describe how you learnt of the existence of this clinic(Required)

Google Search

FaceBook

Friend

Family

Pharmacy

Another Medical Clinic or Hospital

Hotel

College

Other

Tick One Box

Please describe how you learnt of the existence of this clinic(Required)

At What Time is your appointment

Hours

Minutes

What date is your appointment?

Type of Medical(Required)

Face to Face

Telephone / Video

Is visit for General Practice or Sexual Health?(Required)

General Practice

Sexual Health

Sexual Health - Choose one type of Consultation & Price(Required)

6.0 €130 STI Full Screen

7.0 €160 STI Full Screen + Rapid Test for HIV (result in 20 minutes)

10.0 €100 Rapid Blood Test for HIV (results in 20-minutes)

11.0 €80 STI - Treatment of Gonorrhoea (or Chlamydia) following a lab diagnosis result

12 €80 STI - Lab Test to confirm PRIOR Treatment of Gonorrhoea (or Chlamydia) at this clinic was successful

€150 STI PrEP (pre-exposure prophylaxis) Bloods (includes full STI Screen + Prescription for 3 months)

€180 PrEP (pre-exposure prophylaxis) Bloods (includes Rapid HIV Test + full STI Screen + Prescription for 3 months)

Please NAME the Doctor or Clinic or Service or Laboratory that gave you the diagnosis of Gonorrhoea (or Chlamydia) and WHEN (on what Date) did you get this diagnosis(Required)

Do you want US to provide you with a CHAPERONE (Acompanhante)(Required)

Yes

Have you ever been diagnosed with Chlamydia(Required)

Yes

Have you ever been diagnosed with Gonorrhoea(Required)

Yes

Have you ever been diagnosed with Syphilis(Required)

Yes

General Medical - Choose one type of Consultation & Price(Required)

€80 Face-to-Face Consultation

€80 Telephone / Video Consultation

€90 Ear Infection / Wax Removal (I have been using a wax softener ear drops for 2 days)

€130 Consultation & Tetanus

Ear Infection / Wax Removal - please answer YES to confirm that you accept the risks listed below(Required)

If the Doctor recommends Ear Wax Removal, I consent to my ears being irrigated and I understand that ear irrigation carries a minimal risk of perforation to the ear drum and / or bleeding. I accept the advice that I should not fly within 48 hours of treatment. If Ear Wax Removal is recommended by the Doctor, I confirm that I have been using ear drops (a) waxsol for 2 days or (b) Cerumol for 3 days or (c) Otex for 4 days prior to my treatment.

Yes

Do you have medical insurance(Required)

Yes

What is the name of your insurance provider(Required)

Who booked this medical consultation(Required)

I booked it myself

My Insurance booked it

Telephone & Email of the agent that booked this medical for you(Required)

Have you paid already(Required)

Yes

Your payment choices are either (a) Card Payment now or (b) Cash only at the clinic(Required)

Pay Now with Card

I will pay Cash when I attend the Clinic

PLEASE NOTE - if you want to pay with a card you must do so NOW in advance of attending the clinic.There are NO CARD PAYMENT FACILITIES at the clinic - it is CASH ONLY at the clinic.

You must now make a Card Payment(Required)

Pay Now with Card

Cancel My Appointment

Total

Credit Card

Card Details

Cardholder Name

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Patient Questionnaire

Patient Questionnaire

PQS

1. We do not see children under 8 years .......................................... 2. This standalone appointment does NOT mean that the Nassau Clinic has now become your registered GP. If you do not already have your own GP you can find one at https://www.icgp.ie/go/find_a_gp

In a life-Threatening Emergency Dial 999 or 112