Patient of the PracticeNew PatientFirst ContactRe-Contact

    How much pain do you feel?

    MildModerateSevereUncontrollable

    What kind of emergency do you have?

    Medical History

    PLEASE SELECT ANY MEDICAL CONDITIONS WE NEED TO BE AWARE OF:

    High or low blood pressureHeart MurmurStrokeParalysis Artificial Heart ValveAnginaAsthma/ BronchitisHay fever or eczemaBrain surgeryNeurological (nerve) diseasesArthritisHIVHepatitis / JaundiceLiver or Kidney diseaseFainting attacks/giddinessBlackouts or epilepsy

    DO YOU HAVE ANY ALLERGIES?

    ParacetamolIbuprofenPenicillinMetronidazoleAspirinOther

    ARE YOU CURRENTLY TAKE ANY MEDICATIONS?

    AnticoagulantsBisphosphonates for bonesOsteoporosisOther

    ARE YOU PREGNANT?

    YesNo

    Are You A Smoker?

    YesNo

    Are You A Drinker?

    YesNo

    Covid-19 Risk Assessment

    Any new continuous cough?

    YesNo

    Temperature above 37.8°C?

    YesNo

    Shortness of breath?

    YesNo

    Self-isolating/has symptoms/anyone in the family has symptoms/living with a Covid-19 positive person indoors/over 70 years old/has one or multiple underlying medical history risk?

    YesNo

    Covid-19 positive diagnosis?

    YesNo

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    TELL US MORE

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