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2024-08-02T14:31:27+00:00
Telemedicine Clinical Record
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First Name
Last Name
Birth Date
ID number / Passport number
Centre Name
Marie Stopes clinic Cape Town
Marie Stopes clinic in Bellville
Marie Stopes clinic in Hout Bay
Marie Stopes clinic in Phillipi
Marie Stopes clinic in East London
Marie Stopes clinic in Port Elizabeth
Marie Stopes clinic in Durban
Marie Stopes clinic in Bloemfontein
Marie Stopes clinic in Gandhi Square
Marie Stopes clinic in Midrand
Marie Stopes clinic in Pretoria
Marie Stopes clinic in Sandton
Marie Stopes clinic in Soweto
Marie Stopes clinic in Mafikeng
Marie Stopes clinic in Potchefstroom
Contact Number
Consultation Date
Time
Telephone
Cellphone
E-mail Address
Occupation
Emergency Person
Relationship to contact
Physical Address
Street Name & Number
Suburb
City
Postal Code
Building/Complex Name & Number
Medication Delivery Address
Did someone refer/recommend you to Marie Stopes for your visit today?
1. A satisfied Marie Stopes client (could be a friend/family member)
2. A friend or family member who knew about Marie Stopes
3. Referred by the government hospital with letter*
4. A Government nurse or doctor Clinic/Hospital:
5. A private nurse or doctor Name:
6. Saw the Marie Stopes centre or sign and walked in
7. A Marie Stopes ambassador
8. Other Detail:
9. Referred but don't remember by whom
10. I was not referred
11. I am a returning client
Clinic/Hospital Name
Nurse or doctor Name:
Other Detail Please Specify
Did you hear about Marie Stopes via any media in the last 3 months?
1. Went directly to the Marie Stopes website or a link
2. Used an internet search (for a specific health service)
3. Social media (ie. Facebook, Twitter)
4. Public event
5. Brochure/poster
6. Email
7. Radio
8. Television
9. Magazine/ newspaper
10. Billboard/street pole/ taxi wrap
11.SMS/ text message
12. None
Why did you choose Marie Stopes for your visit today?
Would you like to receive further information about Marie Stopes and our services via email?
Yes
No
Demographic Information - Education
Some secondary
Matric
Degree/diploma
Masters
Professional qualification
Demographic Information - Race
Black/African
Coloured
White
Indian/Asian
Other
Demographic Information - Employment
Employed
Unemployed
Student
Reason for visit
Safe abortion care
Contraception
Scan/ pregnancy test
STI screening/treatment
Women's wellness exam
Pap smear
Sterilisation
HIV testing
Other
Please Specify
Medical and Surgical History (Tick all boxes that apply)
Type I Diabetes
Type II Diabetes
Hepatitis/ Jaundice
Porphyria
Epilepsy
Tuberculosis (TB)
Thyroid (hypo/hyper)
Thrombosis/ DVT
Rheumatic Fever
Cancer
Liver disease
Hypo/Hypertension
Headaches/ Migraines
Steroid therapy
Heart condition
Anaemia/ bleeding tendencies
Sexually-transmitted infection (STI)
Asthma/ Respiratory problems
Bladder/ Kidney disease
Other illness
Please Specify
What was the first day of your last normal monthly period (LNMP)?
Did you take medication today?
Yes
No
If yes, please specify time taken
Do you have any allergies to medication?
Yes
No
If yes, please specify to which medications
Have you been admitted to hospital for any reason or for an operation?
Yes
No
If yes, please specify date(s) of admission
Reason(s) for hospitalisation
Only fill in if you are not human
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