Patient Questionnaire

Name: Weekend Doctor STI Clinic
Brand: GP Services
SKU: NAS-WEE-01-01
Price: 60 EUR
Availability: InStock
Rating: 5 (898 reviews)

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Patient Questionnaire

Pre-Consulation Patient Questionnaire

1 of 4 - Patient Details (pre-consultation with the Nassau Clinic)
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/
How or where did you learn about this medical service?
Have you already booked an appointment time?*
- YES
- NO
What is the DATE of your medical consultation?
Date Format: DD slash MM slash YYYY
What is the TIME of your medical consultation ?
24 hour format
: HH
MM
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)*
Number (Apt, Flat or House) and 1st line of Street Name*
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
- NO
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
- NO
Are you living in Ireland for MORE THAN 1 year?*
- YES
- NO
Sex*
- Female
- Male
- Other
Patient's Date of Birth*
Email
Has the Patient recently returned from Brazil, Britain or South Africa*
- YES
- NO
What is the DATE that the Patient arrived back in Ireland?
Date Format: DD slash MM slash YYYY
Has the Patient been tested or made an application to be tested for COVID-19 ?*
- YES
- NO
What is the DATE that the Patient made application / or was tested?
Date Format: DD slash MM slash YYYY
What was the result of the test?*
- Positive
- Negative
- Waiting for the test / test result
What was your reason for getting tested for COVID?*
Did the Patient ever get a POSITIVE result for COVID-19 ?*
- YES
- NO
On what date (approximately) did you test POSITIVE for COVID?*
Date Format: DD slash MM slash YYYY
Did the Patient ever get a NEGATIVE result for COVID-19 ?*
- YES
- NO
On what date (approximately) did you test NEGATIVE for COVID?*
Date Format: DD slash MM slash YYYY
Have YOU or any or anyone in your home been self isolating or restricting your movement in the last month?*
- YES
- NO
What was the START DATE of Self Isolation / Restricted Movements?*
Date Format: DD slash MM slash YYYY
Have you any concerns that you might have COVID-19?*
- YES
- NO
STOP - please go to www.COVIDA.ie & complete the Questionnaire ( find the link below )
go to https://covida.ie/ and wait for the clinic to telephone you. Please do not attend the clinic face to face and wait for your COVID-19 questionnaire to be reviewed. You will receive a telephone call from the clinic.
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
Previously, have you attended Dr. Liam REGAN at this clinic (Nassau Street)?*
- YES
- NO
Do you have medical health insurance?*
- YES
- NO
What is the name of your health insurance provider?
3 of 4 - Risk Factors
Have you an ALLERGY to any MEDICATION?*
- YES
- NO - I do NOT have an ALLERGY to any MEDICATION
List ALL medication that you are allergic to:
Are you pregnant?
- YES
- NO
Are you breast feeding?
- YES
- NO
Are you taking regular MEDICATION?*
- YES
- NO
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)*
- Men's Health
- Women's Health
- Stress, Anxiety, Depression
- Ear
- Eye
- Skin Conditions
- Renew a Prescription
- Vaccinations
- Cold, Flu, Respiratory
- Driving Licence Medical (Group 1 ONLY)
- Additional / Other medical issues not listed above
Please tick boxes that may describe your skin condition:
- Acne
- Cellulitis
- Shingles
- Impetigo
- Hives
- Rashes
- Allergic Reaction
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
- NO
The reason for this question is that Gonorrhoea & Chlamydia can result in Conjunctivitis
Please tick boxes that may describe your Women's Health:
- UTI - Urinary Tract Infection
- Yeast Infection / Candidiasis / Thrush
- Bacterial Vaginosis
- STI - I may need to be tested (blood, urine, swabs)
- Pregnancy
- Contraceptive Pill
- Period Delay Pill
- Emergency Contraception
Please tick multiple boxes that may describe your Men's Health:
- STI - I may need to be tested (Blood, Swab, Urine)
- Erectile Disfunction
- Prostatitis
- PrEP
- Premature Ejaculation Treatment
- Tenderness / Pain in Testicle(s)
- Chlamydia
- Gonorrrhoea
- Genital Herpes
- Genital Warts
- Balanitis
- Penile Yeast (fungal) infection
- Candida
What is your HIV Status?*
- Never had a HIV test before
- Negative when last tested
- Positive
- Positive Undetectable
- Recently tested but awaiting result
Before now, have you ever had an STI TEST?*
- Yes
- No
When was your last STI Test?*
- < 3 months
- 3-6 months ago
- > 6 months ago
- > 1 year ago
- > 2 years ago
- > 3 years ago
When you tested before, did you have any infection?*
- Yes
- No
Tick if you previously had any of the following infections-*
- Chlamydia
- Gonorrhoea
- Syphilis
- Oral Herpes
- Genital Herpes
- Genital Warts
- Hepatitis C
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:blems:
- High Temperature (above 38°C)
- Cough
- Shortness of Breath
- Nausea & Vomiting
- Asthma
- Sinus Infection
- Headaches
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
Have you already PAID for your medical consultation?*
- Yes
- No
Are you attending in FACE-to-FACE or VIDEO / Telephone Consultation?*
- Face-to-Face
- Video / Telephone
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)
- €80 Standard Consultation (Face-to-Face)
- €80 Video / Telephone Consultation
- €90 Ear Wax Removal
- €130 STI Test
- €160 STI Test + Rapid HIV (20 minutes)
- €150 PrEP Blood Test
- €120 Vaccination
- €60 Vaccination
- €1 Test
Total
0,00 €
Credit Card
Card Details
Cardholder Name
Email for Receipt
We will email a payment receipt to this address
Billing Address linked to Card
Address Line 1 Address Line 2 Address Line 3 EIRCODE Country
What is the name of your INSURANCE company that is paying for this consultation?*

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Patient Questionnaire

Patient Questionnaire

Patient Questionnaire

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

STOP - please go to www.COVIDA.ie & complete the Questionnaire ( find the link below )

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

3 of 4 - Risk Factors

4 of 4 - Reason for Medical Consultation?

In a life-Threatening Emergency Dial 999 or 112