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ABOUT
INTRODUCING RANDOX HEALTH
WHAT WE DO
THE SCIENCE EXPLAINED
THE RANDOX GRAND NATIONAL
HEALTH TESTS
IN-CLINIC HEALTH TEST
AT-HOME HEALTH TEST
IV THERAPY
COVID-19
LOCATIONS
HEALTH HUB
NEWS
VIDEOS
HEALTH TESTIMONIALS
CONTACT
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Medical Questionnaire Form
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Forename
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Surname
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Date
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Day
Month
Year
Gender
Address
GP Name
GP Address
Phone Number
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Mobile Number
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Email Address
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Emergency Contact Name
Emergency Contact Number
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Allergies
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Medication
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Covid-19 Cautionary Measure
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Are you or is any of your direct household displaying any symptoms directly related to Covid-19?
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Yes
No
Reported symptoms are shortness of breath, fever, temperature, cough.
Do you have any history of heart disease such as coronary heart disease, congestive heart failure, irregular heart rhythms, heart palpitations, valvular heart disease, heart surgery or myocardial infarctions?
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Yes
No
Do you have a history of any platelet or bleeding disorders, experiencing any abnormal bleeding/bruising, ulcers, blood clots, or are you taking blood thinners?
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Yes
No
Do you have any history of kidney disease such as abnormal kidney function, kidney failure, or dialysis?
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Yes
No
Do you have a history of any platelet or bleeding disorders, experiencing any abnormal bleeding/bruising, ulcers, blood clots, or are you taking blood thinners?
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Yes
No
Do you have any history of brain aneurysms, or surgeries involving the brain?
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Yes
No
Are you over the age of 65?
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Yes
No
Are you 17 years of age or under?
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Yes
No
Have you had any recent dizziness, numbness or tingling, any visions/speech changes or headaches that were severe, sudden onset, or were associated, with vomiting or vision problems or were different than prior headaches?
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Yes
No
Are you experiencing any abdominal pain or chest pain, any shortness of breath, swelling of your legs, fevers, or have you been vomiting blood or noticing any blood in your stools?
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Yes
No
Are you under investigation for, or do you have an autoimmune disorder (such as MS) or existing neurological condition, including epilepsy?
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Yes
No
Have you experienced any recent injuries or trauma?
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Yes
No
Have you, in the last 48 hours, participated in strenuous activity such as marathons, triathlons, fights etc?
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Yes
No
Have you ever been told that you should not receive IV fluids for any reason?
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Yes
No
Have you ever had an allergic reaction to any vitamins/vitamin IV infusion?
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Yes
No
Have you ever had an allergic or adverse reaction to Sulphur based antibiotics?
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Yes
No
Are you or could you be pregnant?
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Yes
No
Are you currently breast-feeding/expressing?
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Yes
No
Have you experienced any diarrhea and vomiting in the previous 48 hours?
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Yes
No
Are you currently being treated for cancer or being seen by a specialist in respect of a cancer diagnosis?
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Yes
No
Do you have any heart or lung conditions?
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Yes
No
Are you diabetic? Have you experienced excessive thirst, excessive hunger or frequent urination?
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Yes
No
Are you currently taking any medication (excluding the oral contraceptive)?
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Do you have any allergies, other than those listed in the questions above?
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Any other medical conditions/symptoms not listed?
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Please provide more information here:
When was the last time you had an intravenous or intramuscular treatment?
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