Carestaff Confidential Patient Intake Screening Form

Free In-Home Patient Consultation

We will contact you within 36 Hours To schedule your visit.
Full Name *

First Name Last Name
Date of Birth

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Your Mobile Phone Number *

Area Code Phone Number
Emergency contact *

First Name Last Name
Emergency Contact's Mobile Phone number *

Area Code Phone Number
Your Home Phone Number

Area Code Phone Number
Describe services requested. Explain why you are seeking a consultation with us?
It is helpful to say when, how it started and how it is affecting you.
Health Screening Questionnaire

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

	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.
Signature *

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