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Dr Robert Pozzi
Dr Ben Parkinson
Dr Michel Genon
Dr Kira James
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Dr Robert Pozzi
Dr Ben Parkinson
Dr Kira James
Dr Michel Genon
Patient Health Questionnaire
Health Questionnaire
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Registration
Patient Health Questionnaire
Please complete in full.
* Mandatory fields
Your full name*
Date of birth*
Your email address*
Who is your treating doctor?*
Dr Robert Pozzi
Dr Ben Parkinson
Dr Kira James
Dr Michel Genon
Do you have, or have you ever had, the following conditions?
Please tick the conditions you have, or have had in the past
Endocrine
Diabetes (Type 1 or 2)
Thyroid Problems
Toggle Next field if previous field yes
Please provide treating Doctor / Details for your Endocrine condition
Cardiovascular
High blood pressure
Cholesterol
Cardiac Surgery
Pacemaker
Other Implantable
Toggle Next field if previous field yes
Please provide treating Doctor / Details for your Cardiovascular condition
Renal
Kidney Problems
Toggle Next field if previous field yes
Please provide treating Doctor / Details for your Renal condition
Liver
Liver Problems
Hepatitis
Toggle Next field if previous field yes
Please provide treating Doctor / Details for your Liver condition
Respiratory
Lung Problems (asthma, emphysema, other)
Toggle Next field if previous field yes
Please provide treating Doctor / Details for your Respiratory condition
Gastrointestinal
Stomach Problems
Gastric Band
Sleeves
Bowel Problems (IBS / IBD / Crohns / Stoma / other)
Toggle Next field if previous field yes
Please provide treating Doctor / Details for your Gastrointestinal condition
Neurological
Epilepsy
Fits
Faints
Stroke
TIA
Neuromuscular diseases (eg: MS, Parkinsons etc)
Other Neurological Problems (eg: Alzheimers, dementia, memory issues, migraine, meningitis)
Toggle Next field if previous field yes
Please provide treating Doctor / Details for your Neurological condition
Psychological
Mental Health
Anxiety
Depression
other
Toggle Next field if previous field yes
Please provide treating Doctor / Details for your Psychological condition
Haematological
Blood
Clotting Disorders
Anaemia
Pulmonary Embolism (lung clots)
Deep Vein Thrombosis (leg clots)
Previous Blood Transfusions
Toggle Next field if previous field yes
Please provide treating Doctor / Details for your Haematological condition
Rheumatology
Rheumatoid arthritis
See a rheumatologist
Toggle Next field if previous field yes
Please provide treating Doctor / Details for your Rheumatology condition
Other
Cancer - specify type in field below
Anaesthetic issues (nausea, vomiting, reactions)
Other
Toggle Next field if previous field yes
Please provide further details and treating Doctor details for these other conditions
Other information
Are you currently taking any medications? Incl over-the-counter, vitamins, fish/krill oil, natural/herbal etc. Incl “as required” such as analgesia, NSAIDs etc
Yes
No
Toggle Next field if previous field yes
Please specify medication / dose / frequency
Anti-coagulants (eg: aspirin, Cartia, Xarelto, Plavix, Iscover, Apixaban, Eliquis, Warfarin etc)
Yes
No
Toggle Next field if previous field yes
Please specify Anti-coagulant medication / dose / frequency
Any allergies – Medication / Food
Yes
No
Toggle Next field if previous field yes
Please specify reaction / medication / dose / frequency
Any previous Surgery or Procedures?
Yes
No
Toggle Next field if previous field yes
Please provide Surgery / Procedure details including date if known
Do you use Prosthetics / Aids / CPAP Machine (incl vision, walking etc)
Yes
No
Toggle Next field if previous field yes
Please provide more details about the Prosthetics / Aids / CPAP Machine (incl vision, walking etc)
Your weight (in kg)*
Your height (in cm)*
Smoking/vaping status
Yes
No
Toggle Next field if previous field yes
How many times a day do you smoke/vape?
If you are an ex-smoker, what date did you stop smoking/vaping?
Do you drink alcohol
Yes
No
Toggle Next field if previous field yes
What is your daily average alcohol intake (number of standard drinks per day)?
Do you perform any sort of physical activity (currently or pre-injury levels)
Yes
No
Toggle Next field if previous field yes
Please provide details of your Physical Activity
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