Patient Questionnaire Form
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Welcome Message From Extreme Doctors

We would like to take this opportunity to welcome you to our practice. We provide General Practice (15-20 min), as well as Integrative Medicine (60 min) consultations and telephone / online consultations.

Our office hours are Monday to Thursday 09:00 - 17:00 and Friday 09:00 - 15:00.
Bookings are essential.

We also request that the patient brings copies of their previous blood results/reports/scans etc. to the consultation, or that they send them electronically via email.

Please fill out these online forms before your first appointment. Please bring your Medical aid identification card, ID and a complete list of all of your medications, as well as the strength and dosages of each one.

Please note that we are a cash or card practice. Medical aid friendly invoices will be provided for medical aid claims/tax purposes. All patients are responsible for their own accounts. Consultations, telephonic consultations, prescriptions, letters, forms, treatments, supplements etc. will be charged for.

We look forward to helping you in your journey to a healthier you.

Yours Sincerely
Dr Steven Gunn
Dr Antony Hofer

NOTE THAT ALL INFORMATION PROVIDED WILL BE KEPT STRICTLY CONFIDENTIAL.   

Yours Sincerely 
Dr Steven Gunn
( B.Sc. Clin Psychol. Microbiol. MB ChB. CVit )
Full Name *
Date  *
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Occupation *
Your Email ( If available )
ID Number
Home Language *
Contact Number 
Home Address *
Work Address *
Medical Aid / Insurance Details *
Main Member Full Names & Title  *
Main Member ID Number *
Option Plan Name  *
Hospital Plan Only 
Clear selection
Name of Next of Kin in case of Emergency *
Relationship to you *
Contact Number of Next of Kin *
Social & Marital Status *
Number of Children Living  *
Number of Children Passed *
Medical Aid History 
Please complete the below medical history as best you can
Allergies *
Sensitivities *
Blood group *
Previous Covid Infections  *
When did you have covid ?  *
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Covid Vaccinations ?  *
How many Vaccinations ? *
Family Medical History
This covers Parents , Grandparents , Brothers & Sisters as best as you can remember ..
Check Box on the following conditions  *
Required
If Cancer .. Who ? *
What type of Cancer ? ( Breast , Prostate , Colon Etc ) *
Further Questions .. *
Required
Obstetrics and Gynaecology History 
Read below ...
Periods / Menstruation  *
Required
Pregnancies
Complete below ...
Pregnancies *
Number of Pregnancies ? *
Number of Miscarriages *
Number of Planned Abortions *
Number of Children  *
Gynecology History ( Uterus , Vagina, Vulva , Ovaries ) *
Required
Surgery & Accidents History  *
Accidents ( eg Motor Vehicle , Falls , Motor Bike Etc ) *
Chemotherapy & Radiation Therapy *
Chemotherapy Or Radiation Dates  *
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Chemotherapy Tablet Names *
Please provide us with your main reason to see Dr Gunn in a few words ( Your primary medical symptom or symptoms )  *
Medical Disorders 
Please list any Medical Disorders which you have had in the past or at present in the following categories..
Brain , Nerves & Psychological 
( eg Stroke , Anxiety , Depression, Epilepsy, ADD, Mental Fatigue ) 
 *
Heart and Blood Vessels 
(eg High Blood Pressure, Heart Attack, High Cholesterol )
 *
Digestive ( GIT ) System 
( eg. Heart Burn, IBS, Diarrheoa, Constipation, Hiatus Hernia, Gluten Sensitivity )
 *
ENT ( Ear Nose and Throat )
( eg Ear Infections, Sinusitis, Tonsillitis, Throat Infection )
 *
Immune System
( eg Autoimmune Diseases, Weak Immune System , Chronic Infections, Cancer Lymphoma )
 *
Lungs, Respiratory 
( eg Asthma, COPD, Emphysema, Bronchitis, Chronic Cough )
 *
Liver & Kidneys & Bladder 
( eg Gall Stones, Jaundice, Fatty Liver, Kidney Stones, Infections, Gout, Hepatitis, Bladder Infections )
 *
Skin 
( eg Eczema, Acne, Allergies, Melanoma, Psoriasis. )
 *
Muscles, Bones & Joints.
( eg Arthritis, Gout, Fibromyalgia, Osteoporosis, Physical Fatique )  
 *
Pancreas, Sugar and Insulin
( eg Diabetes, Type 2, Insulin Resistance )
 *
Blood , Spleen , Bone Marrow
( eg Anemia, Haemochromatosis , Bone Marrow Disease )
 *
Sex Organs ( Male )
( eg Enlarged Prostate, Erectile Dysfunction, Testes Tumour )
 *
Hormones 
( eg Premenstrual Syndrome , Post Menopausal Syndrome, PCOS, Low Testosterone )
 *
Sex Organs ( Female ) & Breasts
( eg Breast Lumps, Fibroadenosis , Ovarian Cysts , Heavy Periods , Sex Pain , Cervix Cancer , Herpes , Endometriosis )
 *
Diet - Enviroment - Travel - Habits History
To answer the following questions just select what is appropriate for you ..
Diet  *
Required
Environment *
Required
Travel *
Required
Travel Continued ...
Have you ever been bitten by Ticks , Insects , Spiders or Mosquitos ? If so which ones ?

 *
Travel Continued ..
( Do you have unexplained rashes , chills or headaches ? )
 *
Required
Habits  *
Required
Habits Continued ...
( Coffee , Regular Tea or Energy Drinks .. ) How many cups / bottles / cans per day ? Please fill in what is appropriate for you ..
 *
Alcohol Consumption *
Required
Thank you for completing our questionnaire. Please submit and we will follow up then come back to you.
Indemnity Form 

Dr Steven Gunn & Extreme Doctors (PTY) LTD. do not make any claims, nor offer any guarantees regarding their therapies, treatment, medication or products.

The patient hereby agrees by informed consent to participate in this consultation, integrative medicine, healthy management program or general practice and will not hold either: Dr Steven Gunn, Extreme Doctors (PTY) Ltd, nor the personnel and health care practitioners liable for any claims or actions concerning the products, treatments, tests or consultation. The patient gives informed consent to the Medical Doctor and the associated healthcare practitioners to view the patient’s file and past or current medical records.

Every patient / guardian is responsible for their own account and any other account with outside laboratories, hospitals, clinics etc.

The account is payable on the day of consultation and treatment. Extreme Doctors (PTY) Ltd also has a no refund / return policy, please inform the doctor or healthcare practitioner of any allergies before any supplements or medication is prescribed. It is the patient’s decision to take the natural supplements or medication prescribed.

Cancellation policy: all consultations or treatments are to be cancelled 48 hours in advance, should there be no cancellation, the patient will be charged the full amount.

The consultation fee is charged at R650 for 15 minutes and R1200 per hour and R850 for follow up consultations. Extreme Doctors (PTY) Ltd. Is a private clinic, therefore consultations, prescriptions, treatments, tests, medication, supplements, letters and forms will be charged for. 

Indemnity Answers *
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