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Online Consultation Form
Once this form has been submitted, Dr Martin will contact you telephonically with a diagnosis and treatment plan.
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* Indicates required question
Surname
*
Your answer
First Name/s
*
Your answer
SA ID Number
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Email
*
Your answer
Cellphone number
*
Your answer
Address
*
Your answer
Medical Aid Number
*
Your answer
Medical Aid Name
*
Your answer
Medical Aid Plan
Your answer
What body region is affected?
*
Hip
Knee
Hand
Required
Duration of Symptoms
*
Days
Months
Years
Other:
Required
Pain
Mild
1
2
3
4
5
Severe
Clear selection
Stiffness
Mild
1
2
3
4
5
Severe
Clear selection
Locking / clicking / snapping
Mild
1
2
3
4
5
Severe
Clear selection
Joint instability (feels like it wants to dislocate)
Mild
1
2
3
4
5
Severe
Clear selection
Pain down the leg / back pain
Mild
1
2
3
4
5
Severe
Clear selection
Loss of feeling / pins + needles
Mild
1
2
3
4
5
Severe
Clear selection
Weakness
Mild
1
2
3
4
5
Severe
Clear selection
Brief description of the traumatic event / development of the current complaint.
Your answer
Which of the following digital* imaging investigations of the affected region have you had? (* the result was saved on a computer)
*
Xray
CT scan
MRI scan
Isotope bone scan
Other:
Required
Date of the latest investigation (month, year, description)
*
Your answer
Where were the imaging investigations performed?
*
Bellville Medical Centre (Morton)
Blaauberg Netcare Hospital (Morton)
Cape Gate Mediclinic (Schnetler)
Cape Town Mediclinic (Morton)
Christiaan Barnard Memorial Hospital (Morton)
Constantiaberg Mediclinic (Cape Radiology)
Durbanville Mediclinic (Schnetler)
Gatesville Medical Centre (Morton)
Helderberg Hospital (Van Wageningen)
Kingsbury Hospital (Cape Radiology)
Klein Karoo Oudtshoorn Mediclinic (CAW Radiology)
Kuils River Private Hospital (Bergman)
Louis Leipoldt Mediclinic (Schnetler)
Milnerton Mediclinic (Morton)
N1 City Hospital (Bergman)
Netcare Parklands Hospital (Bergman)
Paarl Mediclinic (Schnetler)
Panorama Mediclinic (Schnetler)
Plettenberg Bay Mediclinic (Scribante)
Rondebosch Medical Centre (Morton)
Stellenbosch Mediclinic (Winelands)
Strand Private Hospital (Mdunge Mnguni)
Vincent Pallotti Hospital (Morton)
Vergelegen Mediclinic (Winelands)
Worcester Mediclinic (Worcester Radiology)
Sports Science Newlands (Winelands)
Other:
Required
I give Dr Nick Martin permission to view my imaging investigations and to discuss them with a specialist radiologist.
*
Yes
No
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.
*
Yes
No
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