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- Step 1 of 9

Section 1 | Personal Details

Patient's gender

Patient Name

First

Last

Identity Number

Date Of Birth

Work Telephone

Mobile Number

Patient Email Address

Confirm Email

Company/Employer Name

Job Title

Medical Aid Scheme Name

Medical Aid Number

General Practioner's Name (GP)

General Practioner's Number

2.1 | Current Medical Symptoms

Please indicate if you have suffered from any of the following in the last 3 months

Visual disturbances
Wheezing
Shortness of breath
Swollen ankles
A chronic productive cough (>3 months)
Frequent fainting/blackouts or dizzy spells
Frequent thirst or urination
Excessive weight gain or loss
Change in bowel habits or rectal bleeding
Regular headaches
Calf pain with exercise
Changes in colour, size, shape or bleeding moles
Hearing difficulties
Chest pain / Angina
Palpitations
Abdominal cramps
Hoarseness
Loss of appetite
Muscle weakness
Pins and needles
Depression / Anxiety
Frequent heavy snoring
Difficulty in starting / stopping or bleeding in urination

2.2 | Medical history

Please indicate if you have ever suffered from Angina / Heart attack / Abnormal ECG

Age of onset

Please indicate if you have ever suffered from Congenital or rheumatic heart disease

Age of onset

Please indicate if you have ever suffered from Circulatory or vascular disease

Age of onset

Please indicate if you have ever suffered from High cholesterol

Age of onset

Please indicate if you have ever suffered from Stroke

Age of onset

Please indicate if you have ever suffered from High blood pressure

Age of onset

Please indicate if you have ever suffered from Diabetes

Age of onset

Please indicate if you have ever suffered from Asthma

Age of onset

Please indicate if you have ever suffered from Emphysema

Age of onset

Please indicate if you have ever suffered from Chronic bronchitis

Age of onset

Please indicate if you have ever suffered from Insomnia

Age of onset

Please indicate if you have ever suffered from Sleep Apnoea

Age of onset

Please indicate if you have ever suffered from Restless leg syndrome

Age of onset

Please indicate if you have ever suffered from Gastroesophageal Reflux

Age of onset

Please indicate if you have ever suffered from Hepatitis

Age of onset

Please indicate if you have ever suffered from Liver disease

Age of onset

Please indicate if you have ever suffered from Epilepsy

Age of onset

Please indicate if you have ever suffered from Gout

Age of onset

Please indicate if you have ever suffered from Arthritis

Age of onset

Please indicate if you have ever suffered from Osteoporosis

Age of onset

Please indicate if you have ever suffered from Cancer

Age of onset

Please indicate if you have ever suffered from Prostate problems

Age of onset

Please list any past or present health concerns you have:

2.2 | Medical History Females

Are you currently pregnant?

How many weeks pregnant are you?

How Many Pregnancies Have You Had?

Selected Value: 0

How Many Live Births Have You Had?

Selected Value: 0

When last did you have a breast examination?

1 > 6 months
6 > 12 months
2 years
3 years
4 years
5 years >

When was your last pap smear?

1 > 6 months
6 > 12 months
2 years
3 years
4 years
5 years >

Are you currently on contraception or HRT (Hormone Replacement Therapy)?

Please provide details of contraception or Hormone Replacement Therapy

Do you have a history of breast cancer?

Breast Cancer Treatment Received

Breast Cancer Date of Diagnosis

Do you have a history of cervical cancer?

Cervical Cancer Treatment Received

Cervical Cancer Date of Diagnosis

Do you have a history of ovarian cancer?

Ovarian Cancer Treatment Received

Ovarian Cancer Date of Diagnosis

2.3 | Medical History Females

Have you had abdominal surgery?

Date of operation

Have you had peptic ulcer surgery?

Date of operation

Have you had an apendectomy?

Date of operation

Have you had a tonsilectomy?

Date of operation

Have you had a hernia repair?

Date of operation

Have you had wisdom teeth removed?

Date of operation

Have you had your gall bladder removed?

Date of operation

Have you had heart surgery?

Date of operation

Have you had back surgery?

Date of operation

Have you had hip surgery?

Date of operation

Have you had knee surgery?

No
Left
Right
Left and Right

Date of operation

Have you had shoulder surgery?

No
Left
Right
Left and Right

Date of operation

Please list any other surgery that you have undergone

2.4 Allergies

Do you suffer from any allergies?

Please list your known allergies:

2.5 Medication & Supplementation

Are you taking medication for a sleeping disorder, other & supplements?

1. Please list any medication/supplements you are regularly taking:

1. Dosage for the above (e.g. 500mg)

1. Frequency of dosage

1. Reason

2. Please list any medication/supplements you are regularly taking:

2. Dosage for the above (e.g. 500mg)

2. Frequency of dosage

2. Reason

3. Please list any medication/supplements you are regularly taking:

3. Dosage for the above (e.g. 500mg)

3. Frequency of dosage

3. Reason

Comment on the above

OPTIONAL

Please list any medication or supplements you take regularly including sleeping tablets

Appointment Details

How soon do you need to speak to a GP? *

Please describe your problem and symptoms *

How would you like us to help? *

Patient's Current Address *

Address Line 1

Address Line 2

City

State

Zip Code

Have you experienced Covid-19 symptoms in the last 14 days? *

Have you taken a Covid-19 test in the last 5 days? *

What was the result of the test?

Positive
Negative
Don't know/ waiting for result

Patients with symptoms who have a positive test result will be offered a telephone appointment. We may also offer a telephone appointment if you're awaiting the results.