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New Consultation

Patient of the PracticeNew PatientFirst ContactRe-Contact

MildModerateSevereUncontrollable

Medical History

High or low blood pressureHeart MurmurStrokeParalysis Artificial Heart ValveAnginaAsthma/ BronchitisHay fever or eczemaBrain surgeryNeurological (nerve) diseasesArthritisHIVHepatitis / JaundiceLiver or Kidney diseaseFainting attacks/giddinessBlackouts or epilepsy

ParacetamolIbuprofenPenicillinMetronidazoleAspirinOther

AnticoagulantsBisphosphonates for bonesOsteoporosisOther

YesNo

Are You A Smoker?
YesNo
Are You A Drinker?
YesNo

Covid-19 Risk Assessment

Any new continuous cough?
YesNo
Temperature above 37.8°C?
YesNo
Shortness of breath?
YesNo
Self-isolating/has symptoms/anyone in family has symptoms/living with a Covid-19 positive person indoors/over 70 years old/has one or multiple underlying medical history risk?
YesNo
Covid-19 positive diagnosis?
YesNo



19-21 Islington High Street

Angel-Islington, London N1 9LQ

020 7837 2300

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info@londoncitysmiles.com