BetterNOW Healthcare Confidential Patient Intake Screening Form

Confidential Patient History Form
Full name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
E-mail
Your Mobile Phone Number
Area CodePhone Number
Emergency contact
First NameLast Name
Emergency Contact's Mobile Phone number
Area CodePhone Number
Your Home Phone Number
Area CodePhone Number
GP Address (name and location of clinic is sufficient)
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Health Screening Questionnaire

Please answer ALL questions. If you answer YES to any questions please give more details below:

Rows	Yes	No
SKIN - lesions, eczema, psoriasis, skin cancer, moles or rashes, other?
ENDOCRINE - diabetes, hypoglycaemia, thyroid, pancreas, other?
GASTROINTESTINAL - ulcers, hiatus hernia, reflux, diverticulitis, diarrhoea, IBS, other?
BLOOD -anaemia, thrombosis, anticoagulants, leukaemia, other?
LIVER - hepatitis, jaundice, liver disease/dysfunction, other?
MUSCULOSKELETAL -serious injury, accident, disorders of the back, deformity, loss of strenth, pain, arthritis, other?
NEUROLOGICAL - weakness, numbness, other neuropathy, stroke, seizures, neurological disease genetic or acquired, migraine, other?
RESPIRATORY - asthma, COPD, shortness of breath, CF, emphysema, other?
HEART - rheumatic fever, valves, heart attack, murmur, hypo or hypertension, angina, congestive heart failure, malformation, arrythmias, other?
KIDNEY - kidney eg CKD, nephrotic syndrome, bladder, prostate, dialysis other?
INFECTIOUS OR CONTAGIOUS DISEASE - HIV, hepatitis, Covid, other?
CANCER - unexplained weightloss, treatment for cancer
SURGICAL PROCEDURES - excisions, replacements, repairs, trauma, cosmetic, lifesaving, other?
ALLERGIES - are you allergic to any medications, latex, foods, plasters, if you carry an epipen give details below.
DO YOU SMOKE?
DO YOU DRINK MORE ALCOHOL THAN THE GOV GUIDELINE?
DO YOU ABUSE ANY OTHER SUBTANCES OR USE RECREATIONAL DRUGS?
DO YOU HAVE ANY SIGNIFICANT GENETIC OR OTHER DISEASE WITHIN YOUR BLOOD RELATIONS - eg haemophilia, Sickle Cell, CKD, CF, Huntingdon's disease, BRAC1 gene, other?

If you answered YES to any of the above, please give details here:
Please give as much detail as possible including DATES and OUTCOMES
MEDICATION - please list all the tablets, creams, inhalers, dressings, supplements you take here:
Please give doses of drugs and how often you take them.
(optional) LIFESTYLE - please briefly outline your weekly excercise and whether you feel you live/eat healthy lifestyle.
Why are seeking an consultation with us? eg: painful corn, running injury, low back pain, chronic/acute condition
It is helpful to say when, how it started and how it is affecting you.
Patient information - 24 hour cancellation policy
We will ask for the full fee if less than 24 hours notice is given of cancellation unless there are unavoidable extenuating circumstances. You can cancel on-line or by email if necessary.
Patient Signature
I have read, understood and completed this questionnaire to my best ability. By signing this form I am consenting to this information being securely digitally stored in compliance with GDPR and ICO rules. We will not share this information with any third parties without your written consent. I further agree to betterNOW! healthcare's Privacy Policy (available for view on the website).
I am happy to receive:
Signature
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Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Confidential Patient History Form

Health Screening Questionnaire

Patient information - 24 hour cancellation policy

Patient Signature