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Home / Questionnaire

Questionnaire

A. Medical History

Name *

Surname *

Father's Name *

Date of Birth *

Address *

Email *

Phone *

Type of job *

Manual
Desk-based
Self employed
Other

What is your other job name? *

B. Please answer the following questions.

Have you had a high temperature? *

Yes
No

Have you had a new, continuous cough? *

Yes
No

Have you had a loss of, or change to, your sense of smell? *

Yes
No

Have you had a loss of, or change to, your sense of taste? *

Yes
No

Have you been vaccinated for COVID-19? *

Yes
No
1st dose
2nd dose

Have you been contacted by the EODY test and trace services and asked to self-isolate? *

Yes
No

Are you self-isolating after returning or entering the country? *

Yes
No

Does any of the above apply for any member of your household? *

Yes
No

Types of referral *

A&E
G.P
Other

Present complaint *

History of present complaint *

Duration of symptoms *

Previous injury? *

Yes
No

Single Line Text

Fall? *

Yes
No

Road traffic accident? *

Yes
No

Sports injury? *

Yes
No

Pain? *

Yes
No

Stubbing pain? *

Yes
No

Burning pain? *

Yes
No

Dull toothache pain? *

Yes
No

Subsides with painkillers? *

Yes
No

Night pain? *

Yes
No

Activity pain? *

Yes
No

Previous treatment? *

Yes
No

Type of treatment *

Blood tests
Xray
CT
MRI
Other

Other treatment name *

Ischemic heart disease *

Yes
No

Myocardial infraction *

Yes
No

Angina *

Yes
No

Heart Failure *

Yes
No

Atrial Fibrilation *

Yes
No

Hypertension *

Yes
No

Asthma *

Yes
No

COPD *

Yes
No

TB *

Yes
No

Rheumatic fever *

Yes
No

Thyroid dysfunction *

Yes
No

Rheumatoid arthritis *

Yes
No

Osteoarthritis *

Yes
No

Epilepsy *

Yes
No

TIA *

Yes
No

CVA *

Yes
No

Diabetes *

Type 1
Type 2
N/A

Deep vein thrombosis *

Yes
No

Pulmonary embolism *

Yes
No

Kidney Disease *

Yes
No

Blood Disorder *

Yes
No

Cancer *

Yes
No

C. Medications

Fill this section if you have been on medications prior to now.

Medication 1

First

Middle

Last

Medication 2

First

Middle

Last

Medication 3

First

Middle

Last

Drug Allergies *

Yes
No

Drug allergies name *

Previous sugery? *

Yes
No

Please state the surgery *

Orthopaedic implants *

Yes
No

Pacemaker *

Yes
No

CABG *

Yes
No

Anaesthesia issues *

Yes
No
Other

Social history

Activities of daily living *

Independent
Residential home
Carers ( x/day)
Nursing home

Mobility *

Independent
Frame
Stick
Wheel chair

Define distance per day *

Alcohol *

Yes
No

Glasses per day *

Smoking *

Yes
No

Cigarettes/day *

Drugs *

Yes
No

Type of drugs *

Risks of falls *

Yes
No

Dementia *

Yes
No

Height (cm) *

Weight (kg) *

BMI

Sports *

Any attachment?

Click or drag a file to this area to upload.

Maximum file size: 20MB

Privacy Policy *

I accept the privacy policy of this site.

By checking this box, I consent to the processing and storage of my personal data by Dr. Konstantinos Evangelou and I accept the privacy policy, as explained to the website: orthopedikos.org

Please read our full Privacy Policy here.

Dr Konstantinos Evangelou MD, Orthopaedic Surgeon

Trauma and Orthopaedic Surgeon specialised in:
- Hip & Knee Arthroplasty
- Soft Tissue Knee Surgery

+306972908091

+441295 755000 (UK)

drkonstantinos.evangelou@gmail.com

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