Patient Screening Form

Title (required)MrMrsMsMiss

Next of Kin

By completing this section you consent to the practice contacting your next of kin in the event of a medical emergency

TitleMrMrsMsMiss

Medical History Update

Are you (tick all that apply):

Currently pregnantReceiving treatment from a doctor, hospital or clinicTaking any prescribed medicines (e.g. tablets, ointments, injections, or inhalers eydrops, suppositories, nebulisers, the contraceptive pill or HRT)Carrying a medical warning card

Do you suffer from (tick all that apply):

Allergies to any medicines (e.g. penicillin), substances (e.g. latex/rubber) or foodsHay feverEczemaBronchitis, asthma or other chest conditionFainting attacks, giddiness, blackouts, epilepsyHeart problems (e.g. angina, blood pressure problems or stroke)Diabetes (or does anyone in your familyNeurological (nerve) diseases (e.g. 'neuropathies', MS etc.)Arthritis?Bruising or persistent bleeding following injury, tooth extraction or surgeryAny infections diseases (including HIV, hepatitis, TB)Stomach ulcers/hiatus hernia/indigestion

Did you, as a child or since, have (tick all that apply):

Rheumatic feaver, heart murmur or choreaLiver disease (e.g. jaundice, hepatitisKidney diseaseAny other serious illness

Did you, as a child or since, have (tick all that apply):

Blood refused by the Blood Transfusion ServiceA bad reaction to general or local anaestheticA joint replacement or other implantTreatment that required you to be in hospitalHeart surgeryGrowth hormone treatment before the mid 1980sA close relative (parent, sibling, child, grandparent, or grandchild) with Creutzfeldt Jakob Disease (CJD)Steroid treatment

How many units of alcohol do you drink per week? (A unit is half a pint of lager, a single measure of spirits of a single glass of wine/aperitif)

Do you smoke any tobacco products now (or did you in the past)?

Do you chew tobacco, pan, use gutkha or supari now (or did you in the past)?

COVID-19 Screening

1.) Have you previously been diagnosed with COVID-19 or think that you’ve had or have COVID-19? (required)

YesNo

2.) How were you confirmed positive?

I think I had itI had a positive nasal swab testI had a positive blood testI had a positive saliva testI currently have symptoms and am waiting for a test

3.) If you have had COVID-19, how were you confirmed negative?

I was diagnosed negative by a nasal swb testI show antibodies to COVID-19 with a blood testMy doctor said I no longer have it because I don't have any symptomsI don't have any symptoms, so I don't have it

4.) If you have had COVID-19, when were you confirmed negative?

24 Hours agoToday10 Days after testing

5.) Have you had any of these symptoms in the last 14 days:

A high temperature - this means you feel hot to touch on your chest or back (you do not need to measure your temperature)A new, continuous cough - this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual)A loss or change to your sense of smell or taste - this means you've noticed you cannot smell or taste anything, or things smell or taste different to normalShortness of breath or tightness of the chest - this means shortness of breath without over exertion

6.) Have you been contacted by NHS Track & Trace service?

YesNo

7.) If yes, have you completed a mandatory isolation?

YesNo

8.) Have you travelled to any 'high risk' areas that require a quarantine when returned? If yes please confirm you have completed your quarantine.

YesNoYes I completed quarantine

Some medical conditions have been associated with more severe COVID-19 disease. The following questions are an attempt to determine your risk:

9.) Do you have high blood pressure?

YesNo

If you have high blood pressure, is it controlled?

YesNo

10.) Do you have respiratory problems?

YesNo

11.) Do you have any autoimmune disorders?

YesNo

12.) Are there any other conditions you would like to report?

Disclaimer:
By submitting this form, I confirm the information is correct to the best of my knowledge.