newpatient

New patient enquiry

Please Fill the form below and let us know what appointment type you need. We will get back soon to you for more updates.
Name

First NameLast Name
First name*
Surname (last name)*
Gender*
Mobile Phone Number (enter 0 if you do not have one)*
Phone Number

Area CodePhone Number
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityCounty

Postal codeCountry
E-mail Address*
example@example.com
Have you previously attended a clinic with Mr Laniado?*

Yes, as a private patientYes, an NHS patientNoOther
If Yes, please state regarding what and when?
Appointment Type
Please tell us what your consultation is about?*

Prostate cancer risk assessment, e.g. for high PSAProstate cancer treatment (HIFU, Retzius-sparing prostatectomy, other)Urinary symptoms assessmentPelvic pain (e.g. prostatitis)Blood in the urineUrinary tract infectionsBlood in the semenBPH treatment (e.g. Rezum, UroLift, HoLEP, Aquablation)OtherOther
Please provide information below about your condition by filling in the box below and by uploading files including letters from other doctors, scans (ultrasound, MRI, CT), biopsy, blood and urine results if you have them.

Thank you
If relevant, please (1) describe your condition, (2) how if affects you, (3) what you have tried so far to help and (4) your expectations
Please upload previous medical correspondence, scan reports (e.g. CT, MRI, ultrasound), biopsy, blood & urine results if you have them by click the button below to browse your computer and select the relevant files. Otherwise, please email them to pa@sageurology.co.uk.

Browse Files

Cancelof
Do you take any medication by mouth, inhalers, skin patches or otherwise?

YesNo
Please enter ALL the medication whether it is by mouth, inhalers, skin patches or others
Do you have allergies to have medications or other substances?

YesNo
Please enter any allergies you have to medications or other substance
Have you had any biopsies or operations before, e.g. on the prostate, the abdomen such as hernia repairs, appendicectomy, gall bladder, or exploratory operations?

YesNo
Please enter the operations you have had and the dates if you know them:
Now for some questions about your general health. Please answer as best as you can. An approximate or closest answer is fine, so please do not worry if you are not sure.
Do you have or have you had problems with blood supply to the heart leading to a heart attack?*

NoYes
Please select one of the options below or type in the box*

NoYes - a heart attack that I never felt but was found by accident on an ECG or other testYes - a heart attack more than 6 months agoYes - a heart attack in the last 6 monthsOther
Do you have or have you had problems with the blood supply to the heart or chest pain on exertion or angina?*

NoYes
Do you have or have you had problems with the blood supply to the heart or angina? Or type in the field*

NoYes - mild chest pain on activity (angina) OR coronary stent or bypass (CABG) more than 6 months ago OR test showing coronary artery diseaseYes - coronary artery bypass (CABG) or stent in last 6 months, persistent chest pain on activity (angina)Yes - chest pain (angina) occurring at any timeOther
Do you have or have you had problems with heart failure? The symptoms are short of breath on lying flat, swollen ankles, feeling tired all the time*

NoYes
Please select an option if you have you had problems with heart failure (shortness of breath on lying flat, swollen ankles, tired all the time) in the empty box*

NoYes - shortness of breath that improved with treatment OR shortness of breath when you exert yourself OR shortness of breath at nightYes - shortness of breath that limits your activities or for which you needed to go into hospital in last 6 monthYes - admission into hospital in last 6 months for heart failure and heart weakly pushing bloodOther
Do you have or have you had problems with an irregular pulse or palpitations?*

NoYes
Do you have or have you had problems with an irregular pulse or palpitations?*

NoYes - I have atrial fibrillation (AF) and/or pacemakerYes - I have shortness of breath that limits my activities and/or for which I needed to go into hospital in last 6 monthYes - I was admitted into hospital in last 6 months for heart failure or heart weakly pushing blood
Do you have or have you had high blood pressure?*

NoYes
Do you have or have you had high blood pressure?*

NoYes - and BP ok with medicines or not needing medicationYes - BP a little too high despite medication or problems with dizziness, nose bleeds and headachesYes - BP much too high
Do you have or have you had problems with the veins or venous circulation to your legs or arms?*

NoYes - an old clot in the leg (deep vein thrombosis, DVT) and not on treatment anymoreYes - a clot in the leg (DVT) treated by injection or tablets OR a clot in the lungs (PE) more than 6 months agoYes - a clot in the lungs (PE) less than 6 months ago OR a filter put in your body to prevent more clots
Do you have or have you had problems with the arterial circulation to your legs or arms?*

NoYes - pain in the legs when active, or an aneurysm in the belly or previous treatment for an aneurysm or aneurysm less than 6 cmYes - surgery for poor circulation more than 6 months agoYes - surgery for poor circulation less than 6 months ago or aneurysm more than 6 cm
Do you have or have you had problems with the lungs and breathing due to asthma, bronchitis or emphysema?*

NoYes - shortness of breath that is made better with treatment such as inhalersYes - shortness of breath that limits activitiesYes - shortness of breath and you need supplemental oxygen when active or at rest at home
Do you have or have you had problems with the liver or oesophagus?*

NoYes - chronic hepatitis without cirrhosis, chronic liver disease on biopsy or bilirubin level in the blood high (more than 51mmol/L)Yes - cirrhosis, compensated liver failure, portal hypertension with moderate symptomsYes - portal hypertension and bleeding from oesophagus in last 6 months (jaundice, high bilirubin in the blood)
Do you have or have you had problems with stomach ulcers?*

NoYes - ulcers treated with medicinesYes - ulcers needing surgery or a small blood transfusionYes - ulcers in the last 6 months needing a large blood transfusion
Do you have or have you had problems with malabsorption or inflammatory bowel disease such as Crohn's disease or ulcerative colitis?*

NoYes - treated with medicines, surgery or with complications
Do you have or have you had problems with the pancreas?*

NoYes - long term (chronic) pancreatitis but no long term other problems or complicationsYes - chronic pancreatitis and problems with absorbing nutrients, bleeding from the gut and poor control of blood sugar (diabetes)Yes - chronic pancreatitis with major complications
Do you have or have you had kidney problems?*

NoYes - and creatinine less than 265 micro mol/litreYes - on regular dialysis or creatinine more 265 micromol/LitreYes - on acute dialysis with other organ systems failing
Do you have or have you had diabetes?*

NoYes - controlled by tabletsYes - either poorly controlled on tablet or controlled with insulin injections and no complicationsYes - the diabetes has caused problems with my eyes (retinopathy), nerves (e.g. peripheral neuropathy), heart (e.g. angina/heart attack), kidneys or circulation to the legs
Have you ever had a stroke or TIA?*

NoYes a TIA or stroke with complete recoveryYes - an old stroke with residual problemsYes - a recent stroke with significant problems
Do you have or have you ever had memory problems?*

NoYes - but I can completely take care of myselfYes - and I need help supervising meYes - severe and I need full support the activities of daily life
Do you have paralysed arms or legs?*

NoYes - but I can completely take care of myselfYes - and I can do some but not most of my care and I need a wheelchairYes - and I need full support for activities of daily living
Do you have multiple sclerosis, Parkinson's disease or other long-term condition affecting your nerves or muscles?*

NoYes - but I can get around and mostly take care of myselfYes - and I can do some but not most of my careYes - and I need full support for activities of daily living
Do you have or have you ever had a psychiatric problem*

NoYes - major depression or bipolar disorder controlled by medicationYes - schizophrenia controlled by medication or uncontrolled depressionYes - and I recently attempted suicide
Do you have a rheumatological condition such as rheumatoid arthritis, polymyositis, Lupus, connective tissue disorder)?*

NoYes - but controlled well with ibuprofen/naproxen or other NSAIDSYes - and I need steroids or immunosuppressant medicationsYes - severe causing my kidneys, heart, brain or other nerves to work badly
Do you have AIDS?*

NoYes - but I have no symptoms and I have more 200 CD4+ cells per micro litreYes - with an AIDS associated illness and I have less than 200 CD4+ cells per microlitreYes - severe AIDS
Do you have or have you had cancer (e.g. bowel, lung, pancreatic, melanoma)?*

NoYes - diagnosed and treated more than 5 years ago and there is no spread of cancerYes - diagnosed and treated less than 5 years ago and there is no spread of cancer (i.e. no metastases)Yes - newly diagnosed cancer not yet treated, or cancer that is uncontrolled or has spread outside into other areas of the body
Do you have or have you had leukaemia or myeloma*

NoYes - last treatment was more than 1 year agoYes - diagnosed in last 12 months, or just had first remission or long-term suppressive therapyYes - disease has relapsed and is out of control
Do you have or have you had lymphoma?*

NoYes - last treatment was more than 1 year agoYes - diagnosed in last 12 months, or just had first remission or long-term suppressive therapyYes - disease has relapsed and is out of control
Do you drink alcohol?*

NoYes - I used to drink too much but not nowYes - I drink too much and it gives me social and medical problems, and my behaviour is a problemOther
Do you take recreational drugs?*

NoYes - I used to take recreational drugs too much but not nowYes - I use too much and it gives me social and medical problems, and my behaviour is also a problemI would prefer not to dayOther
Do you know your height and weight?*

No - I don't knowYes - my body mass index (BM) is less than 30Yes - my body mass index (BMI) is between 30 and 37Yes - my body mass index (BMI) is 38 or moreOther
Thank you very much for completing the form. The information is held confidentially.
Should be Empty:

New patient enquiry

Appointment Type

Please provide information below about your condition by filling in the box below and by uploading files including letters from other doctors, scans (ultrasound, MRI, CT), biopsy, blood and urine results if you have them.

Thank you

Now for some questions about your general health. Please answer as best as you can. An approximate or closest answer is fine, so please do not worry if you are not sure.