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Patient Questionnaire
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Patient Questionnaire
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Patient Questionnaire
PQS
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We do not offer medical consultations to children under the age of 8 years
Have you already been given your appointment time?
(Required)
Yes
No
Before completing this patient questionnaire, you must first book an appointment (a) online via www.Nassau.ie/book or (b) by telephoning the clinic on 015242848
Date of Birth
(Required)
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Sex
(Required)
Male
Female
Other
Are you pregnant
(Required)
Yes
No
Have you any concerns that you might be pregnant
(Required)
Yes
No
Are you breastfeeding
(Required)
Yes
No
Name
(Required)
First
Last
Phone
(Required)
Email
Address Search (in IRELAND)
(Required)
Search
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
No
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
No
Do you have any concerns that RIGHT NOW you MAY have Monkey Pox
(Required)
Yes
No
Do you have any concerns that RIGHT NOW 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
Are you vaccinated against Hepatitis A
(Required)
YES
NO
Are you vaccinated against Hepatitis B
(Required)
YES
NO
Are you vaccinated against HPV Human Papillomavirus
(Required)
YES
NO
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
In the last 2 DAYS did you take a COVID Test
(Required)
Yes
No
COVID19- Did your ever test positive using Antigen or PCR
(Required)
Yes
No
COVID19 - in last 2 days 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
Is your LIVER (hepatic) impaired
(Required)
Yes
No
Are your KIDNEYS (renal) impaired
(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 One Box
Please describe how you learnt of the existence of this clinic
(Required)
At What Time is your appointment
(Required)
Hours
:
Minutes
AM
PM
AM/PM
What date is your appointment?
(Required)
Day
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Year
2023
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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)
Not Available A Rapid Blood Test for HIV (results in 20-minutes)
€80 STI - Treatment of Gonorrhoea (or Chlamydia)
€80 STI - Lab Test to confirm PRIOR Treatment of Gonorrhoea (or Chlamydia) at this clinic was successful
€100 Cryotherapy (Remove Genital Warts)
€150 STI PrEP Blood Test
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)
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
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
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
In a life-Threatening Emergency Dial 999 or 112