SEX ASSIGNED AT BIRTH*

Male

Female

FIRST NAME of patient (as shown on PASSPORT)*
First Name / Forename / Given Name / Prénoms as printed on your Passport

LAST NAME of patient (as shown on PASSPORT)*
Last Name / Surname / Nom as printed on your Passport

PATIENT DATE OF BIRTH (as printed on PASSPORT)*
Day
Month
Year

Age

WARNING - Patient must be 8 years or older

REGULAR MEDICATION - do you take regular medication*

Yes

No

List regular medication

DOCTOR Name or MEDICAL CLINIC name who last prescribed this medication*

Are you ALLERGIC to any medication*

Yes

No

List medication that you are allergic to

Do you have any any underlying medical conditions – for instance, liver or kidney disease or mental health issues?*

Yes

No

Please explain these medical conditions

Reason for visit*

Respiratory

Gastrointestinal

Skin

Ear Infection

Ear Wax

Eye Infection / Conjunctivitis / Red Eye

Sexual

Urinary Tract Infection

Accident / Injury / Fall

Medication Needed

Drug Test of Urine

Back Pain

Mental Health

Headache / Migraine

Concussion

Pregnancy

Breast lump

Breast mastitis

Testicular Lump

Heart

Bite

Vaccine

Haemoroids

Alcohol dependency / withdrawal

Other Reason

Respiratory*
Chest Infection
Breathing
Sinus
Throat
Nose
Asthma
Inhaler

Do you wear contact lenses*

YES I DO wear contact lenses

NO I do NOT wear contact lenses

Have you been using antiobiotic ear drops during the past 2 weeks*

Yes I have been using ABX

No I have NOT been using ABX

Have you been using wax softening ear drops - during the past 2 days*

Yes I have been using wax softener

No I have NOT been using wax softener
An example of such ear drops are Waxsol or Cerumol

If the Doctor recommends wax removal (ear irrigation with water) do you (1) consent and accept the risks and (2) accept the advice regarding flying (as set out at 2 below).*

Yes to Consent

No to Consent
(1) 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. (2) I accept the advice that I should not fly within 48 hours of treatment.

Gastrointestinal*
Diarrhoea
Acid Reflux / Heartburn
Bloating
Constipation
Food Poisoning

Skin*
Scabies
Fungal Toe
Fungal Skin
Acne
Rash
Infection may need antibiotics
Infection may need steroids
Infection after bite or sting

Sexual (test results from the laboratory can take up to 7 business days)*
STI Screen
Symptoms of Chlamydia need test
Symptoms of Gonorrhoea need test
Symptoms of Syphilis need test
Recent sexual partner has a lab diagnosis
Chlamydia Diagnosed by Nassau Clinic need treatment
Chlamydia Diagnosed by SH24 need treatment
Chlamydia Diagnosed by another laboratory need treatment
Gonorrhoea Diagnosed by NASSAU CLINIC need treatment
Gonorrhoea Diagnosed by SH24 need treatment
Gonorrhoea Diagnosed by another laboratory need treatment
Syphilis Diagnosed need treatment
Urinary Tract Infection
Pain Urinating
Discharge
Symptoms of scabies
PrEP Pre Exposure Prophylaxis
HSV Herpes (cold sores)
HPV (warts) Human Papilloma Virus
Erectile Disfunction
Balinitis (inflammation of the foreskin)
Penis Glans fungal infection
Contraception
PEP n/a - GO TO ED within 72 hours Post Exposure

Sorry but PEP is only available at the Emergency Department of any Hospital and must be taken with 72 hours (3 days) of the potential exposure to HIV.

What is the name of the laboratory that diagnosed your infection*

Urinary Tract Infection*
Urinary Tract Infection
Pain Urinating
Discharge
STI Screen
Symptoms of Chlamydia need test
Symptoms of Gonorrhoea need test
Symptoms of Syphilis need test
Recent sexual partner has a lab diagnosis
Chlamydia Diagnosed need treatment
Gonorrhoea Diagnosed need treatment
Syphilis Diagnosed need treatment

Accident / Injury / Fall*
Head Injury
Fainting
Back
Hand
Arm
Fingers
Shoulder
Knee
Ankle sprain
Elbow
Toes / Gout
Concerned about DVT Deep Vein Thrombosis
Tetanus
May need stitches
Removal of stitches
Work Accident
Car Accident
Bone / Muscle / Ligaments

Medication Needed*
Blood Pressure
Cholesterol
Inhaler
Antibiotic
Lost Medication
Repeat Prescription

Name each medicine needed (name, dosage, frequency and duration)*

Mental Health*
Anxiety
Insomnia
Stress
Mood Low

Pregnancy*
Blood test to confirm pregnancy
Pregnancy support
Abortion services
Fertility blood test

Vaccination*
Hepatitis
Tetanus
HPV Human Papilloma Virus
Travel Vaccine

Why are you doing the drug test

Court appearance

Employer

Child custody

Other

What is the OTHER reason

Drug Test of Urine - what are you preferences
The Doctor will supervise your provision of a urine sample

I accept Doctor supervision

I accept Doctor supervision but I will also bring a friend with me

I accept Doctor supervision but I also want the clinic to provide a chaperone

Are you worried about particular drugs that the test might detect

Yes there are certain drugs I am worried about -

No I am not concerned about any drugs being detected.

List the drug(s) that may be detected

Other reason*

Have you ever tested positive for HEPATITIS B infection*

Yes I did have HEPATITIS B

No I did NOT have HEPATITIS B

Have you ever been treated for a SYPHILIS INFECTION*

Yes I have been treated for SYPHILIS

No I have NOT been treated for SYPHILIS

How recent was your treatment for SYPHILIS*

Treated within the last MONTH

Treated within the last SIX MONTHS

Treated MORE THAN SIX MONTHS ago

Sexual Preferences*

I date Females Exclusively

I date Both Males and Females

I date Males Exclusively

Do you take PrEP medication

Yes I take PrEP

No I do NOT take PrEP

Sexual Preferences*

I date Females Exclusively

I date Both Males and Females

I date Males Exclusively

Do you take PrEP medication

Yes I take PrEP

No I do NOT take PrEP

Who prescribes PrEP for you

What is your HIV Status*

Never Tested for HIV Before

Negative for HIV when last tested

HIV Positive

Are you breast feeding*

Yes

No

Are you PREGNANT*

Yes

No

Number of Weeks you are Pregnant
Please enter a number from 1 to 40.
Choose between 1 and 40 weeks

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Patient Questionnaire

Patient Questionnaire

PQX np

Step 1 of 4

In a life-Threatening Emergency Dial 999 or 112