ID for Power Automate
First Name
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LastName
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DOB
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Do you have any of the following iron deficiency related symptoms?
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Fatigue
Shortness of breath
Decreased exercise tolerance
Dizziness
Palpitations
Headaches
Restless legs
Leg Cramps
Hair loss (Alopecia)
Craving for ice/crunchy foods (Pica)
Other
Other:
Please answer the following questions to help us gauge the impact of your iron deficiency symptoms on your day to day life
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Not at all
A little bit
Somewhat
Quite a bit
Very much
I feel fatigue
Not at all
A little bit
Somewhat
Quite a bit
Very much
I feel weak all over
Not at all
A little bit
Somewhat
Quite a bit
Very much
I am too tired to eat
Not at all
A little bit
Somewhat
Quite a bit
Very much
I have trouble finishing things because I’m tired
Not at all
A little bit
Somewhat
Quite a bit
Very much
I need to sleep during the day
Not at all
A little bit
Somewhat
Quite a bit
Very much
I have energy
Not at all
A little bit
Somewhat
Quite a bit
Very much
I have trouble starting things because I’m tired
Not at all
A little bit
Somewhat
Quite a bit
Very much
I feel tired
Not at all
A little bit
Somewhat
Quite a bit
Very much
I have to limit my social activities because I’m tired
Not at all
A little bit
Somewhat
Quite a bit
Very much
I am able to do my usual activities
Not at all
A little bit
Somewhat
Quite a bit
Very much
I feel listless (washed out)
Not at all
A little bit
Somewhat
Quite a bit
Very much
I need help doing my usual activities
Not at all
A little bit
Somewhat
Quite a bit
Very much
I am frustrated by being too tired to do the things I want to do
Not at all
A little bit
Somewhat
Quite a bit
Very much
Have you had an iron infusion in the past
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Yes
No
How long ago was the last infusion?
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Did it help you feel better?
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Yes
No
Unsure
Did you have an side effects from the infusion?
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Yes
No
Can you describe these side effects?
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Are you currently taking oral iron supplements?
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Yes
No
Have you previously taken iron supplements?
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Yes
No
Did oral iron supplements help you?
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Yes
No
Unsure
Have you had any side effects from oral iron supplements?
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Yes
No
What side effects?
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Nausea/vomiting
Constipation
Other
Other:
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Are you currently pregnant
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Yes
No
How many weeks+days pregnant are you today?
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Do you normally get heavy periods/menstrual losses?
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Yes
No
Unsure
N/A
How many bleeding days do you get on average per cycle?
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On the heaviest day of your period, how often would you change your pad/tampon/cup etc?
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Do you have any blood in your bowels, dark/tarry motions or other bowel symtoms?
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Yes
No
Please describe:
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Do you have any of the following bowel issues?
Coeliac Disease
Ulcerative Colitis
Crohn's disease
Bleeding haemorrhoids
Diverticular disease
Bowel Cancer
Weight loss surgery
Other
Other:
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Do you have any other medical conditions?
Diabetes
Polycystic Ovarian Syndrome
Liver Disease
Kidney Disease
Fatty Liver Disease
Overweight/Obesity
Autoimmune Disease
Other
Other:
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Have you ever had any of the following bowel procedures?
Colonoscopy
Gastroscopy
Capsule Endoscopy
When was this last done
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Were there any abnormalities, can you outline these?
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