Online Consultation Form
Once this form has been submitted, Dr Martin will contact you telephonically with a diagnosis and treatment plan.
Surname *
First Name/s *
SA ID Number
Date of Birth *
MM
/
DD
/
YYYY
Email *
Cellphone number *
Address *
Medical Aid Number *
Medical Aid Name *
Medical Aid Plan
What body region is affected? *
Required
Duration of Symptoms *
Required
Pain
Mild
Severe
Clear selection
Stiffness
Mild
Severe
Clear selection
Locking / clicking / snapping
Mild
Severe
Clear selection
Joint instability (feels like it wants to dislocate)
Mild
Severe
Clear selection
Pain down the leg / back pain
Mild
Severe
Clear selection
Loss of feeling / pins + needles
Mild
Severe
Clear selection
Weakness
Mild
Severe
Clear selection
Brief description of the traumatic event / development of the current complaint.
Which of the following digital* imaging investigations of the affected region have you had? (* the result was saved on a computer) *
Required
Date of the latest investigation (month, year, description) *
Where were the imaging investigations performed? *
Required
I give Dr Nick Martin permission to view my imaging investigations and to discuss them with a specialist radiologist. *
I understand that a physical examination will be required to confirm my diagnosis. The outcome may alter the diagnosis and may require a change in the treatment plan. *
Submit
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