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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I CONSENT TO MY PERSONAL DATA BEING COLLECTED AND STORED AS PER THE PRIVACY POLICY.I CONSENT TO MY PERSONAL DATA BEING COLLECTED AND STORED FOR THE PURPOSE OF MARKETING COMMUNICATIONS.