New Patient Practice Intake Form Personal DetailsName *Age *County of Residence *Select Insurance *Please select an optionVHILayaIrish LifeGarda Medical AidESB Prison Officers Medical SocietyPrison Officers Medical SocietyNo Medical Insurance/Self PayNational RugbyCounty BoardClubSchoolOtherMedical insurance details *Occupation *Primary sport (if any)Left or Right Hand Dominant? *LeftRightSummary of Medical ProblemToday's consultation relates to *Left kneeRight kneeLeft shoulderRight shoulderOtherIf other, please describe here *When did this problem start? *Is this problem a result of *A sports injuryA worlplace injuryAn accidentOtherGradual or sudden onset? *GradualSuddenDescription of symptoms in work and/or every day life: *Symptoms at night *Impact on sports & recreation *Any other impact? *Is there a legal case ongoing or planned in relation to this matter? *YesNoTreatment to dateGP Treatment *Physical/Physiotherapy *Injections *Surgery *Any other treatment? *Medical / Surgical HistoryPast / Current Medical Conditions (heart/lungs/ neurological) *Previous surgery *Are you a diabetic? *YesNoInsulinNon-insulinAllergies? *YesNoPlease list your allergies *List of current medications *Do you take any of the following? *WararfinPlavixAspirinHRTContraceptive pillNoneGP and Physiotherapist DetailsGP Name and Full Address *Physio name, full address and email address *Referring doctor / physio name, full address and email address *Are you happy for us to communicate with your gp & physio regarding your treatment under our care ? *YesNoAdministrative DetailsFull name *Full address *Date of Birth *Contact number *Email AddressNext of Kin Name *Relationship to Patient *Next of Kin Contact Number *Medical Insurance DetailsPlease select your insurance provider *Please select an optionVHILayaIrish LifeGarda Medical AidESB Prison Officers Medical SocietyPrison Officers Medical SocietyNo Medical Insurance/Self PayOtherPlease specify your insurance providerPlan name and policy numberDate Policy First Commenced *Have you completed your waiting period? *YesNoHave you had continued cover with another insurance provider? *YesNoWho was the provider & date of end of that policy *Please confirm here that you accept liability for payment of fees if declined by your insurance provider *I acceptI do not acceptSubmit formPlease do not fill in this field.