Thank you for participating in our Patient Pathways Program, I looking forward to working with you. To obtain the best outcome from the scheduled phone consult please complete the following pre assessment questionnaire. These questions will help me to get to know you and to formulate a treatment summary that can be sent to you or to any of your health team. I may not be able to provide answers to your specific care but will be able to a professional who can help you.

You may not have the answers to all of these questions, so please just complete as many as you can.  Once complete, click the Submit button at the bottom.

If you wish to save your responses you click the Save button at the bottom and complete the form at a later date.

Many thanks

Michele Hemmings,
Patient Pathways Nurse (Mito Foundation)

Data Collection

All the information gathered during the consultation and pre-consult questionnaire will remain confidential. All the information is kept in a secure CC-DR database and on the secure Mito Foundation server.

As the Patient Pathways Program is a pilot program, research will be completed by CC-DR using all the information in their database to review the effectiveness of the Program and to identify future services. Once again, data will only be used for this purpose if consent is provided below and any information that would identify you will not be published.