Patient Questionnaire

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Patient Questionnaire

Pre-Consulation Patient Questionnaire

"*" indicates required fields

Are you attending in FACE-to-FACE or VIDEO / Telephone Consultation?*

Face-to-Face

Video / Telephone

Have you any concerns that you might have COVID-19?*

YES

Due to COVID concerns are you willing to switch to Telephone / Video Consultation rather than Face-to-Face Consultation?

YES

1 of 4 - Patient Details (pre-consultation with the Nassau Clinic)

Nassau Clinic, Weekend Doctor provides urgent out-of-hours PRIVATE medical care when your regular GP is not available. Continuity of care is provided through your own GP. Complete ALL 4 Sections before submitting this form. By submitting this form you agree to (a) wear a face mask during all face-to-face consultations & (b) our privacy policy & "Terms of use" as set out on our home page http://www.nassau.ie/

Please choose the medical service that you need?*

Choose STI Treatment you require*

€160 Complete STI Screen (Rapid HIV in 20 minutes + Blood Test + Swabs)

€130 STI Blood Test + Swabs

€100 STI Rapid HIV only (20 minutes)

€100 Cryotherapy (Genital Warts)

€150 STI PrEP Blood Test

Have you already booked an appointment time?

YES

What is the DATE of your medical consultation?

What is the TIME of your medical consultation ?

24 hour format

How or where did you learn about this medical service?

Patient's Cellphone / Mobile Telephone Number?*

(a) Check that the telephone number is accurate. (b) On arrival at the Clinic ensure your mobile telephone has sufficient battery power and enough call credit to make a call to ask us to open the front door (there is NO intercom).

RE INPUT Telephone Number (Do Not Copy & Paste)

It is really important that your telephone number is accurate

What is your 7 character EIRCODE?*

RE INPUT YOUR EIRCODE (Do Not Copy & Paste)

Address*

Patient's First Name (or 1st Initial)?*

Patient's Last / Family Name / Surname (or Initial)?*

Do you have a PPSN Number (issued by the Irish Government)?*

YES

Note - we do NOT need to know your actual Personal Public Service Number, we simply need to know if you have a PPS Number in the event that we need to refer you to an Emergency Department of a Hospital, as the hospital may ask for your PPSN.

Are you a European Union Passport holder?*

YES

Are you living in Ireland for MORE THAN 1 year?*

YES

Other

Sex*

Female

Male

Other

Patient's Date of Birth*

Have you been vaccinated against COVID-19?*

YES FULLY VACCINATED

PARTIAL VACCINATION - 1 injection

NOT VACCINATED

Did the Patient ever get a POSITIVE result for COVID-19 ?

YES

On what date (approximately) did you test POSITIVE for COVID?

2 of 4 - Patient's GP (Doctor's Name & Medical Clinic)

Your GP Doctor - Name & Medical Centre?*

Who was the Doctor that you last attended - Name & Medical Centre?*

When did you last attend a Doctor or Medical Clinic?

During last 1 month

During last 6 months

> 1 year ago

I never visited a Doctor or Medical Clinic in Ireland

Do you have medical health insurance?

YES

What is the name of your health insurance provider?

Previously, have you attended Dr. Liam REGAN at this clinic (Nassau Street)?

YES

3 of 4 - Risk Factors

Have you an ALLERGY to any MEDICATION?*

YES

NO - I do NOT have an ALLERGY to any MEDICATION

If you ARE ALLERGIC - please list of medication that you are allergic to -

Are you pregnant?*

YES

Are you breast feeding?*

YES

Are you taking regular MEDICATION?*

YES

List ALL medication that you take:*

What Doctor last prescribed this medication and when?

4 of 4 - Reason for Medical Consultation?

Main Reason for Medical Consultation (Choose Only One)*

Which one of the following best describes your sexual relationships?*

Exclusively with WOMEN

With both WOMEN and MEN

Exclusively with MEN

Please tick boxes that may describe your skin condition:*

Please tick boxes that may describe your Ear problem:*

Ear Infection

Ear Wax Removal

Swimmer's Ear

Please tick boxes that may describe your Eye condition:*

Stye

Conjunctivitis

Have you ever tested positive for Gonorrhoea or Chlamydia*

YES

The reason for this question is that Gonorrhoea & Chlamydia can result in Conjunctivitis

Please tick boxes that may describe your Women's Health:*

Please tick multiple boxes that may describe your Men's Health:*

What is your HIV Status?*

Before now, have you ever had an STI TEST?*

Yes

When was your last STI Test?

When you tested before, did you have any infection?*

Yes

Tick if you previously had any of the following infections-*

Please tick boxes that may describe your Stress, Anxiety, Depression:*

Depression

Panic Attacks

Stress

Please tick boxes that may describe your Cold, Flu, Respiratory conditions:*

Prescription - what is the medication, dosage & frequency?*

What vaccine(s) do you need?*

Please provide a brief description of the Additional / Other medical issues not listed above:*

Who is responsible for arranging this consultation?*

PERSONAL - I am responsible for making & paying for this booking

TRAVEL INSURANCE - is responsible for making & paying for this booking

What is the name of your INSURANCE company that is paying for this consultation?*

Have you already PAID for your medical consultation?*

Yes

How did you pay?*

Paid when making the online booking

Paid via https://www.nassau.ie/pay-online/

You must pay in advance for a VIDEO / Telephone Consultation - Pay Now?*

YES Card Payment now

NO - please cancel this appointment

How do you want to pay?*

I will bring CASH to Clinic (we cannot accept cards at clinic)

CARD payment NOW

Choose Type of Medical Consultation*

(This will allow us to calculate the correct Payment Amount)

Total

Credit Card

Card Details

Cardholder Name

Email for Receipt

We will email a payment receipt to this address

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Patient Questionnaire