GP CONSULTATION FORM - Amae Clinic

Welcome to AMAE Clinic’s Online Consultation Check!

At AMAE Clinic, we are committed to providing you with the best care tailored to your needs. This short questionnaire, which takes about 7–10 minutes to complete, helps us determine whether an online consultation is suitable for your situation.

Your answers will guide us to ensure your safety and provide the most effective care. Let’s get started!

Who is this consultation for?

Myself My child (Note: Children must be booked under a parent/guardian account.) Another adult (They need to create their own account and book independently.)

Are you currently located in Ireland?

Yes No

Note: Our services are only available for residents currently in Ireland.

Before proceeding, please confirm the following to ensure an online consultation is suitable for you:

Are you experiencing any of these urgent symptoms?

If yes, please seek emergency assistance immediately.

Chest pain or tightness (possible heart attack)
Facial drooping or slurred speech (possible stroke)
Severe breathing difficulties
Sudden loss of vision
Acute confusion or drowsiness
Severe pain (abdominal, back, or testicular)
Significant bleeding or blood loss

No urgent symptoms confirmation

I confirm that I am not experiencing any of these urgent symptoms.

In-Person Assessment Requirements

Are you seeking care for any of the following conditions?

(These require in-person assessment.)

Ear pain or discharge
Breast lumps
Suicidal thoughts or self-harm concerns
Urinary tract infection symptoms
Testicular lumps or pain

Yes No

Do you need a prescription for controlled or injectable medications? (Examples include sleeping tablets, morphine, contraceptive injections, or vaccinations.)

Yes No

Why are you booking this consultation? (Please describe your symptoms, their duration, treatments you’ve tried, and any other relevant details.)

Are you seeking treatment for a sore throat or skin condition (e.g., rash)? (If yes, we will ask you to upload a photo to assist the GP in making a safe assessment.)

Sore throat Skin condition Something else

Upload Photos for Sore Throat Assessment

Please upload between 2 to 4 images.
Only image files are accepted (e.g., JPG, PNG, GIF).
Ensure the photos are clear and well-lit.
Capture your throat from different angles for better assessment.
Avoid using flash to prevent glare.
Make sure your face is fully visible in the photos.

Upload Photos for Skin Condition Assessment

Photo Upload Guidelines:

Please upload between 2 to 4 images.
Only image files are accepted (e.g., JPG, JPEG, PNG, GIF, WebP).
Ensure the photos are clear and well-lit.
Capture the affected area from different angles for better assessment.
Avoid using flash to prevent glare.
Ensure the skin condition is clearly visible in the photos.

Select Images to Upload: You must upload at least 2 images and no more than 4.

If you would like to provide any images that you believe may be helpful, please upload them here.

Please ensure that the photos are clear, well-lit, and relevant to your condition to assist our medical professionals in making an accurate assessment.

Do you have any known allergies to medications?

Yes No

If Yes, specify: Include the medication and the reaction experienced

Are you currently taking any medications, including over-the-counter or supplements?

Yes No

If Yes, specify: Include the name, dosage, and frequency

Do you have any current or past medical or mental health conditions?

Yes No

If Yes, specify

Have you had any surgeries or medical procedures in the past?

Yes No

If Yes, specify

Are there any significant medical conditions in your family history?

Yes No

If Yes, specify

Your height:

Unit:

Your Weight:

Unit:

Do you smoke or have you ever smoked?

Yes, I currently smoke Yes, I previously smoked but have stopped No, I have never smoked

How many cigarettes do you smoke per day?

More than 20 per day Less than 20 per day Social smoker, e.g. at weekends Other

Please, specify

When did you stop smoking?

Less than one year 1 - 5 years More than 5 years

Do you drink alcohol?

Yes No

On average, how many units of alcohol do you consume per week?

Less than 11 units 11–17 units 18–30 units More than 30 units

We understand it can be challenging to calculate this accurately. To make it easier, here are some common drinks and their approximate standard unit values in Ireland:

Pint of Beer/Lager/Cider (568 ml): 2–2.3 units
Glass of Wine (175 ml): 2.1 units
Single measure of Spirits (35.5 ml): 1 unit
Bottle of Wine (750 ml): 9 units
Can of Lager (330 ml): 1.7 units

When did you last have your blood pressure measured?

Within the last 6 months Over 6 months ago I cannot remember

Please use the input below to enter your blood pressure:

SYS

DIA

Please confirm that you understand the following:

Consultations address one issue per session to ensure quality care.
Each consultation lasts up to 10 minutes.
Connecting from a private and distraction-free location is essential.
AMAE Clinic’s team expects patients to treat staff with respect at all times.

I understand and agree to the terms above.

Service Confirmation

Welcome to AMAE Clinic’s Online Consultation Check!

Are you experiencing any of these urgent symptoms?

Are you seeking care for any of the following conditions?

Upload Photos for Sore Throat Assessment

Upload Photos for Skin Condition Assessment

Photo Upload Guidelines:

Sorry, lads and lassies! 🍀