Language
English (UK)
Afrikaans
New Patient Enrollment
Drs Watt & Jotia
Personal Information
Name
*
First Name(s)
Last Name
Identity number
*
Date of Birth
-
Year
-
Month
Day
Date
Age
*
Gender
*
Please Select
Male
Female
Other
Current Date
-
Month
-
Day
Year
Date
Age in years
Age in months
Contact Number:
*
Format: 000 000 0000.
E-mail
*
example@example.com
Address:
*
Street Address
Street Address Line 2
City / Town
Province
Postal Code
Work status
*
Employed
Unemployed
Occupation
*
Employer
*
Work number
*
Desired appointment date
🛈 Note: Your selected date is a preference only. We will check availability and confirm your appointment. If your chosen date is unavailable, we will schedule the closest available date or time and notify you. Kindly note: Both doctors' schedules are extremely full.
Appointment
*
already scheduled
still to be scheduled
select desired appointment date
*
Medical aid information
Do you belong to a medical aid?
*
Yes
No
Medical scheme
*
GEMS, Discovery, Polmed, BCIMA, Bonita, ect.
Option
*
Ruby, Coastal Saver, Marine, Basic, Standard, ect.
Number
*
Member type
*
Main Member
Dependent
Dependent Code
*
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Medical history
All information is handled strictly confidential
Medical conditions
Do you have any chronic conditions?
*
Yes
No
Choose any relevant medical conditions you have been diagnosed with
*
Allergic Rhinitis (Severe/Chronic)
Anxiety Disorders
Asthma
Bipolar Disorder
Cancer
Cataracts
Chronic Obstructive Pulmonary Disease (COPD)
Dementia
Diabetes Mellitus Type 1
Diabetes Mellitus Type 2
Eczema (Severe/Chronic)
Epilepsy
Glaucoma
Gout
Hearing Loss (Chronic/Severe)
Heart Disease
Hepatitis B or C
HIV/AIDS
Hyperlipidemia (High Cholesterol)
Hypertension (High Blood Pressure)
Hyperthyroidism
Hypothyroidism
Inflammatory Bowel Disease (IBD) (e.g., Crohn’s Disease, Ulcerative Colitis)
Irritable Bowel Syndrome (IBS)
Kidney disease
Liver disease
Major Depression
Osteoarthritis
Osteoporosis
Polycystic Ovary Syndrome (PCOS)
Post-Traumatic Stress Disorder (PTSD)
Psoriasis
Rheumatoid Arthritis
Schizophrenia
Sleep Apnea
Systemic Lupus Erythematosus (SLE)
Tuberculosis (current or previous)
Vitiligo
Other
Are you pregnant?
*
Yes
No
Unsure
What is the first day of your last menstrual period?
*
-
Month
-
Day
Year
Date
Medication
Are you taking any medication currently?
*
Yes
No
Please list it here (mention the name, dosage and times per day prescribed)
Surgical History
Do you have any past surgeries or hospitalizations?
*
Yes
No
List operations/hospitalizations here (mention the date, name of operation, the specialist and the hospital)
*
Recent Medical Tests & Specialist Visits
Blood test
When was your last blood test done?
*
Please Select
Within the last month
1-3 months ago
4-6 months ago
7-12 months ago
More than a year ago
Never been done
I don’t remember
Which laboratory conducted the test?
*
Please Select
Pathcare
Ampath
NHLS
Other
Specialist visits
Have you visited a specialist in the last 12 months?
*
Yes
No
Speciality
*
Cardiologist (Heart Specialist)
Endocrinologist (Diabetes, Hormones)
Neurologist (Brain, Nerves)
Rheumatologist (Arthritis, Autoimmune Diseases)
Orthopedic Surgeon (Bones, Joints)
Gynecologist (Women's Health)
Urologist (Kidney, Bladder, Men's Health)
Pulmonologist (Lung Specialist)
Psychiatrist (Mental Health)
Other
Reason for visit
*
Social History
Do you have any allergies?
*
Yes
No
List allergies here
*
Do you smoke? (cigarettes, vape, "okka" pipe)
*
Yes
No
How many cigarettes per day?
*
On days when you vape, how many puffs do you take?
*
Please Select
1-5 puffs
6-10 puffs
11-20 puffs
more than 20 puffs
Do you consume alcohol?
*
Yes
No
How often do you consume alcohol?
*
Please Select
Daily
4-6 times per week
2-3 times per week
Once a week
1-3 times per month
Rarely
What type(s) of alcohol do you usually consume?
*
Beer 🍺 (330ml = 1 standard drink)
Wine 🍷 (150ml = 1 standard drink)
Spirits 🥃 (25ml shot = 1 standard drink)
Cider / Cooler
Other
How many standard drinks do you consume per occasion?
*
Please Select
1 drink
2 drinks
3-4 drinks
5-6 drinks
7+ drinks
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Emergency Contact
Next of kin
Contact name:
*
First Name
Last Name
Relationship
*
Contact Number
*
Format: 000 000 0000.
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Consent & Declaration
Tick if you agree
*
I consent to the collection and use of my personal and medical information by Drs Watt & Jotia for the purpose of my medical treatment.
I give my consent for Drs Watt & Jotia to request, access and obtain copies of my recent blood results and specialist reports and understand that this information will be used solely for my medical care and to ensure continuity of care.
I understand that I am responsible for payments not covered by my medical aid.
I authorize Drs Watt & Jotia to contact me via SMS, email or phone for appointment reminders and health-related information.
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