Arthritis and Pain Clinic Consultant Rheumatologist

Location:

Aut Even Hospital
Freshford Road, Kilkenny Ireland
Tel: 00353-56-7721726
Fax: 00353-56-7789846
Email: rheumatologyclinics@gmail.com
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Pain Clinic

Please fill out this form to request a pain case review. One of our practice members will get back in touch with you soon.

YOUR DETAILS
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YOUR CURRENT PROBLEM






PAIN SCALE
Using the diagram below, click on the crayon which best represents your pain and hold your mouse button to draw on the affected area of the body.

 

 



 



TREATMENTS




IMPORTANT INFORMATION : Please Click on either Yes or No.

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PLEASE CLICK IF YOU HAVE HAD ANY OF THE FOLLOWING PROBLEMS:
High blood pressure Asthma Cancer of any type
Depression Heart surgery Sleep Apnoea
Radiotherapy Reflux Angina
Diabetes Type 2 Chemotherapy Migraine
Heart attack/s Diabetes Type 1 Long standing infections
Liver problems Cardiac stent/s DVT blood clots
Hepatitis Kidney problems Strokes
Siezures / Fits Abdominal surgery Gastric ulcers


MEDICATIONS:
Enter Medication here


INVESTIGATIONS:

Please click on any investigations that you have had:

X-rays (Which joint(s) was the X Ray performed on and what was the result? Please include if a chest X ray was performed and what was the result?)

CT scan

MRI scan (Which joint(s) was the M.R.I performed on and what was the result?)

Other

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If you want a detailed medical report on your condition or a second opinion,please pay by credit card $75 inclusive of VAT and a comprehensive medical report will be e mailed to you : * Yes No

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