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Patient Questionnaire
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Patient Questionnaire
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Patient Questionnaire
PQX
Step
1
of
6
16%
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
Did you ever attend this before
*
Yes
No
DOCTOR's Name & Address (your regular or most recent Doctor)
*
Dr REGAN or the Nassau Clinic is NOT your Doctor - this is an emergency out of hours service only
Pharmacy Name & Address where we should send any prescription
*
Have you already been given your appointment time?(Required)
*
Yes
No
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 the clinic on 015242848
Date of Appointment
*
DD dash MM dash YYYY
DAY of appointment
Today
Tomorrow
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
TIME of appointment
Morning before1200h
Afternoon 1200h to 1700h
Evening after 1700h
MORNING
*
0600h
0615h
0630h
0645h
0700h
0715h
0730h
0745h
0800h
0815h
0830h
0845h
0900h
0915h
0930h
0945h
1000h
1015h
1030h
1045h
1100h
1115h
1130h
1145h
AFTERNOON
*
1200h
1215h
1230h
1245h
1300h
1315h
1330h
1345h
1400h
1415h
1430h
1445h
1500h
1515h
1530h
1545h
1600h
1615h
1630h
1645h
EVENING
*
1700h
1715h
1730h
1745h
1800h
1815h
1830h
1845h
1900h
1915h
1930h
1945h
2000h
2015h
2030h
2045h
2100h
2115h
2130h
2145h
FIRST NAME of patient
*
LAST NAME of patient
*
PATIENT DATE OF BIRTH
*
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
1
2
3
4
5
6
7
8
9
10
11
12
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
GENDER
*
Male
Female
REASON for VISIT (you can tick more than one box)
*
Throat
Respiratory
Ear Infection
Ear Wax Removal
Eye
Sinus
Skin
Gastro
Sexual
Urinary Tract Infection
Repeat prescription
Leg
Lost medication while travelling
Back
Hand
Knee
Tetanus
Vaccine Hepatitis
PrEP
Treatment of Chlamydia or Gonorrhoea
Have you ever been treated for a SYPHILIS INFECTION
*
Yes
No
Sexual Preferences
*
Females Exclusively
Both Males and Females
Males Exclusively
What is your HIV Status
*
Never Tested Before
Negative when last tested
HIV Positive
Are you breast feeding
*
Yes
No
Are you PREGNANT
*
Yes
No
Country where your Mobile Cell Phone is registered
*
353 IRELAND
54 Argentina
61 Australia
43 Austria
591 Bolivia
55 Brazil
359 Bulgaria
1 Canada
56 Chile
385 Croatia
357 Cyprus
420 Czech
45 Denmark
358 Finland
33 France
49 Germany
30 Greece
852 Hong Kong
36 Hungary
354 Iceland
91 India
971 Israel
39 Italy
81 Japan
383 Kosovo
965 Kuwait
371 Latvia
370 Lithuania
352 Luxembourg
60 Malaysia
222 Mauritius
373 Moldovia
383 Montenegro
31 Netherlands
47 Norway
92 Pakistan
351 Portugal
40 Romania
7 Russia
966 Saudi Arabia
381 Serbia
65 Singapore
421 Slovakia
34 Spain
46 Sweden
66 Thailand
90 Turkey
380 Ukraine
598 Uruguay
1 USA
58 Venezuela
84 Vietnam
MOBILE / CELL PHONE of the Patient
*
REPEAT MOBILE / CELL PHONE of the Patient
*
EMAIL of the Patient
*
We will email a payment receipt to this address
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
ALLERGIES - are you allergic to any medication
*
Yes
No
ALLERGIES - Please list any medication that you are allergic to
REGULAR MEDICATION - do you take regular medication
*
Yes
No
REGULAR MEDICATION - Please list ALL medication that you take
Are you IMMUNOCOMPROMISED
*
Yes
No
Why are you immunocompromised
EIRCODE (Irish Postal Code) if known
Address (in Ireland) Line 1
*
Address (in Ireland) Line 2
Address (in Ireland) Line 3
Address (in Ireland) Line 4
Have you paid already
Yes
No
Payment Method that you want to use
Card
Cash
Choose Payment Amount
*
€80 Standard Consultation
€90 Ear Wax Removal
€100
€130
€150
€160
€1 Test Payment
Total
0,00 €
Credit Card
*
In a life-Threatening Emergency Dial 999 or 112