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Patient Questionnaire

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Step 1 of 4

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CONSENT - do you give permission to us to communicate with you by SMS Text Message and / or Email*
- Yes
- No
YES response is obligatory if you wish to have a medical appointment with this clinic
Do you have health insurance*
- Yes
- No
Country of Your Insurer*
- Irish Insurance -
- NOT Irish Insurance -
Irish Insurer Name*
- Irish Life
- VHI
- Laya
- Level Health
- Study and Protect
- Another IRISH Insurer
Choose a pharmacy*
(if a prescription is needed, the Doctor will sent it electronically to your pharmacy of choice)
- NEAREST PHARMACY TO CLINIC
- Dawson St BOOTS
- Grafton St BOOTS
- Grafton St HICKEYS
- St. Stephens Green SC BOOTS
- O'Connell St. HICKEYS
- Henry St BOOTS
- Henry St HICKEYS
- Henry St CHEMIST WAREHOUSE
- Harolds Cross HICKEYS Late Night
- Jervis St SC BOOTS
- Phibsboro HICKEYS
- Baggot St Lower 6 DOWLING (beside Doheny & Nesbitts Pub)
- Baggot St Lower 134-135 BOOTS (near Toners Pub)
- Baggot St Upper 10 MEAGHERS (beside canal)
- Baggot St Upper 32 BOOTS (beside canal)
- Dorset St Late Night PARKS
- Donnybrook LLOYDS
- Donnybrook BOOTS
- Donnybrook PURE
- Thomas St REILLYS
- Thomas St Liberties CARE PLUS
- Rathmines BOOTS 302 Lower Rathmines Road
- Rathmines LIFE Swan Centre
- Rathmines ROCHES 163/165 Upper
- Rathmines RATHMINES PHARMACY 114 Rathmines Road Lower
- None of the Above Pharmacies
Name your preferred Pharmacy Name & Address where we should send any prescription*
Did you ever attend this clinic before*
- YES I DID previously attend Nassau Clinic
- NO I NEVER attended Nassau Clinic before
DOCTOR's Name & Address (your regular or most recent Doctor)
We will NOT write to your Doctor unless you ask us to do so. You must type a response. It cannot be blank. Dr REGAN or the Nassau Clinic is NOT your Doctor - this is an emergency out of hours service only
What type of medical appointment do you want (choose one)*
- Face to Face at Clinic
- Video Consultation
Have you already been given your appointment time?(Required)*
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 or the clinic on 015242848 or visiting the clinic and speaking with the manager about appointment times
- Yes
- No
Time of appointment*
: Hours
Minutes
24 hour clock e.g. a 6pm appointment = 18:00 hours. Please enter your appointment time by either (a) typing over the 00 : 00 time or (b) use the up and down arrows for hours and minutes.
Days to Appt*
Date of appointment*
Appointment is TODAY
Appointment is TOMORROW
Appointment is in TWO DAYS
Appointment is in THREE DAYS
Appointment is in FOUR DAYS
Appointment is in FIVE DAYS
Appointment is in SIX DAYS
Appointment is in ONE WEEK

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
Do you take roaccutaine

YES I DO take roaccutaine

NO I do NOT take roaccutaine
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
What type of medical consultation do you need*

001 FACE to FACE CONSULTATION €100

002 VIDEO CONSULTATION €100

003 EAR WAX REMOVAL €100

005 Cryotherapy (Freezing of Male Genital Warts) €120

006 STI Full Screen €150

007 STI Full Screen + Rapid HIV Test (result in 30 minutes) €200

008 PrEP Bloods + full STI screen €150

008.5 PrEP Bloods + full STI screen + DoxyPEP €200

009 Same Day PrEP + full STI screen + Rapid HIV Test (results in 30 minutes) €200

009.5 Same Day PrEP + DoxyPEP + full STI screen + DoxyPEP + Rapid HIV Test (result in 30 minutes) €250

010 HIV Test only (Rapid Result in 30 minutes) €100

011 STI Treatment of Gonorrhoea (or Chlamydia) which has already been diagnosed by a laboratory €100

012 STI – Lab Test (to confirm successful treatment of infection in the past 2 weeks) €100

013 Cholesterol Blood Test (min. 12 hours fasting) €100

014 hCG Pregnancy Blood Test €100

015 Thyroid Function Blood Test €100

016 Drug Test for Workplace or Custody or Court Appearance €100

018 Vaccination (Gardasil 9) against the Human Papilloma Virus (HPV) €275

019 Tetanus + Consultation with the Doctor €150

020 Hepatitis A or Hepatitis B or both Hepatitis A & B (combined) €100

050 DoxyPEP €50
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
Cryotherapy (freezing of male genital warts)
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 - possible Break or Fracture*
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
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

EMAIL of the Patient
We will email a payment receipt to this address
EIRCODE (Irish Postal Code) if known
Full Address (in IRELAND)*

RECENT MEDICAL - have you been with a Doctor or in a Hospital in the last 4 weeks*

Yes

No
Reason for your recent medical visit and the name of the Doctor or Hospital*
Is your IMMUNE system weak*

Yes

No
This mean that your body's natural defence against infection doesn't work as expected
Why is your immune system weak
Telephone of the Patient*
Use the correct COUNTRY CODE by selecting the correct FLAG in the dropdown
Is it the telephone number of the patient*

Yes it IS the patients telephone number

No it is NOT the patients telephone number
Who is the owner of that telephone number*

Number belongs to parent or guardian

Number belongs to spouse or partner

Number belongs to family member

Number belongs to friend

In a life-Threatening Emergency Dial 999 or 112

Nassau Clinic, Weekend Doctor, Suite 17, First Floor, Morrison Chambers, 32 Nassau Street, Dublin 2, D02 XW77.
Telephone Call: (01) 524 2848

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Weekend and Evening Medical Doctor | Nassau Clinic | Nassau Street, Dublin 2 Copyright © 2026 All Rights Reserved.