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EL
EN_GB
Home
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Services
News
Contact us
Make an appointment
New patient form
Send email
Live chat
EL
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Questionnaire
Questionnaire
Please enable JavaScript in your browser to complete this form.
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
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