New Patient Form

Do you have any Covid symptoms

Yes
No

GDPR Consent

I give my consent for my personal data and medical files to be used in this questionnaire.

First Name*

Last Name*

Date of Birth*

Country*

Ireland
UK

Address*

Phone Number*

Email address

Name of GP*

Allergies*

Yes
No

Allergies details*

Do you take any of the following blood thinning medications*

Other

Have you been admitted to a Hospital or Nursing Home in the last 6 months:*

Yes
No

(if yes please give details below)

Hospital Details*

Have you ever been treated for MRSA or been in contact with someone who has had MRSA:*

Yes
No

MRSA answer details*

Health Insurance Details:

Please select your health insurer:*

(please tick the appropriate)

Insurance Plan:

Policy Number:*

How long have you had health insurance:*

Have you ever had a break in your health insurance cover:*

Yes
No

(If yes please give details below)

Insurance break details*

Next of Kin Details:

Name (next of Kin)*

Relation*

Phone Number (next of kin)*

Have you previously had hip or knee surgery?

Hip
Knee
None

What Year?

Please enter a number from 1950 to 2040.

Who was the surgeon?

Details of Symptoms

Location of your pain / symptoms:*

Left Hip
Right Hip
Both Hips
Left Knee
Right Knee
Both Knees
Other

(if other please give details below)

Pain details*

Date of Onset of Pain / Symptoms*

Please provide an accurate date

(It is very important to provide an accurate date of onset of symptoms - your health insurer will determine based on this date as to whether or not you are covered for orthopaedic surgery. Some insurance plans may have excesses or co-payments)

How bad is your pain on a scale of one to ten:*

(one being very mild and ten being very severe)

Does the pain disturb your sleep:*

Yes
No

How far can you walk comfortably without pain:*

How many pain killers do you take every day:*

What painkiller(s) do you take?

How effective are your pain killers*

Do you have any problems with your:
(if yes please give details below)

Blood pressure*

Yes
No

Blood pressure problem details

Heart*

Yes
No

Heart problem details

Lungs*

Yes
No

Lungs problem details

Do you need to take any of the following medications:
(if yes please give details below)

Heart medication*

Yes
No

Heart Medication details*

Diabetes medication*

Yes
No

Diabetes Medication details*

Do you have any other health problems:*

(if yes please give details below)

Yes
No

Health problems details*

This field is hidden when viewing the form

Administrative-email

Call Us

Email Us

Health Insurance Details:

Next of Kin Details:

Details of Symptoms