Patient Screening Form

Title (required)MrMrsMsMissMxDr

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

Please note; if you have previously completed the form within 6 months and there are no changes to your medical form, you can leave this section blank and just complete the fields which are marked as required and the covid screening questions.

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 eye drops, 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 fever, 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

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

YesNo

Are any of your household currently in isolation? (required)

YesNo

Have you had any of these symptoms in the last 14 days (required):

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 exertionI have had none of these symptoms

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