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Patient Questionnaire
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Patient Questionnaire
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Patient Questionnaire
PQS
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Date of Birth
(Required)
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Sex
(Required)
Male
Female
Other
Are you pregnant
(Required)
Yes
No
Are you breastfeeding
(Required)
Yes
No
Name
(Required)
First
Last
Phone
(Required)
Email
Address Search (in IRELAND)
Search
Hidden
Admin Address Control
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Show Next Qs
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
No
Main Reason for Medical Consultation (Choose Only One)
(Required)
UTI
Sexual Health
Ear
Eye
Respiratory, Flu, Cough
Skin Condition
Prescription Renewal
Driving Licence Medical
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 you may have Monkey Pox
(Required)
Yes
No
Do you have any concerns that you may have Monkey Pox
(Required)
Yes
No
Do you have any concerns that you may have Monkey Pox
(Required)
Yes
No
Do you take PrEP medication
(Required)
Yes
No
What is your HIV Status
(Required)
Never had a HIV test before
Negative when last tested
Positive
Positive Undetectable
Recently tested but awaiting result
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
No
Have you been outside Ireland in the last 2 weeks
(Required)
Yes
No
Did you ever take a COVID Test
(Required)
Yes
No
COVID19- Did your ever test positive using Antigen or PCR
(Required)
Yes
No
COVID19 - in last 2 weeks did you test positive
(Required)
Yes
No
When date did you test positive?
(Required)
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Did you ever attend a Medical Clinic / Doctor in Ireland
(Required)
Yes
No
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
No
Name the Doctor / ED / Hospital & the reason for your visit
(Required)
Are you ALLERGIC to any medication
(Required)
Yes
No
Allergic to : - List the medication
(Required)
Do you take any regular medication
(Required)
Yes
No
Regular Medication - please list
(Required)
Are you immunocompromised
(Required)
Yes
No
Can you provide some additional information
(Required)
Are you a smoker / or have you ever been a smoker
(Required)
Yes
No
How many cigarettes per day
(Required)
Do you have Asthma
(Required)
Yes
No
Did you ever attend this clinic with Dr. Liam REGAN before
(Required)
Yes
No
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 As Many Boxes as you wish
Please describe how you learnt of the existence of this clinic
(Required)
Do you know the time of your medical
(Required)
Yes
No
At What Time
(Required)
Hours
:
Minutes
AM
PM
AM/PM
What date is your appointment?
(Required)
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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)
€130 STI Full Screen
€160 STI Full Screen + Rapid Test for HIV (result in 20 minutes)
€100 STI - A Rapid Blood Test for HIV (results in 20-minutes)
€100 Cryotherapy (Remove Genital Warts)
€150 STI PrEP Blood Test
€1 Test Payment
General Medical - Choose one type of Consultation & Price
(Required)
€80 Face-to-Face Consultation
€80 Telephone / Video Consultation
€90 Ear Infection / Wax Removal
€120 Consultation & Tetanus
€1 Test Payment
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
No
Do you have medical insurance
(Required)
Yes
No
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
No
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
You must now make a Card Payment
(Required)
Pay Now with Card
Cancel My Appointment
Total
Credit Card
Card Details
Cardholder Name
In a life-Threatening Emergency Dial 999 or 112