Get Checked Out. Check list. Please fill this book in and bring it back to the GP surgery. Name:... Date of birth:... Get Checked Out check list
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- Lawrence Reynolds
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1 Get Checked Out Check list Please fill this book in and bring it back to the GP surgery Get Checked Out check list Name:... Date of birth:... male female
2 Are you married, single, divorced or widowed? Address:... Next of kin: Realation: Address: Tel:... Tel: Medication How do you take your list medication?
3 Eating and drinking Indigestion tummy ache when you eat Food allergies/intollerances Being sick Do you drink alcohol Do you eat inedible food? Diffculty swallowing Coughing when eating or drinking Has your weight changed yes no Please bring your weight chart if you keep one Height... 2
4 Breathing Coughing that won t go away (more than 3 weeks) Chest infection Coughing up blood Unusual coloured spit Wheeze Hay fever allergies asthma, chronic obstructive pulmonary disease Breathlessness Do you smoke? Heart Chest pain Swelling of the ankles 3 Palpitations feeling your heart beat
5 Brain Do you have epilepsy How often/number per month - changes? Under the care of epilepsy specialist (neurologist) When last seen Faints/blackouts/stroke passing out Pins and needles Arm or leg weakness Please bring epilepsy charts if you keep them. 4
6 Mobility Stiffness or diffculty moving Slowing of movements Pain when moving Falling or tripping Changes in posture/mobility Mobility equipment used Swelling or redness in limbs occupational therapy or physiotherapy input Skin Dry or itchy skin Prescribed skin cream Warts Cold sores Sores or open wounds 5 Pressure area concerns
7 Urine Pain when you wee? Urine infection Wee more often? Blood in your wee? Diffculty in getting to the toilet in time? Bowels Constipation hard poo or can t go to the toilet Diarrhoea watery poo and going too much Bleeding from your bottom Diffculty getting to the toilet on time Changes in bowel pattern Please bring your bowel chart if you keep one. 6
8 Women s health Change in periods i.e. heavy, bleeding in between painful etc Vaginal discharge Is contraception needed Are you sexually active? Contraception used? Please bring your menstruation chart if you have one Breasts Lump in breasts (or any other concern about breasts) Discharge from nipples 7 Pain or tenderness unsual shape, skin puckering or lumps
9 Men s Health Testicular lump/swelling/changes Diffculty having a wee Are you sexually active? Contraception used? Mental Health! Any diagnosis Any worries about memory/ confusion Any change in behaviour since last review e.g. aggression, self-injury, over-activity Are you aware of any risk to the patient or others If yes, have you spoken/referred to other health and social care professionals 8
10 You can ask questions at your health check Dentist Do you go to the dentist regularly? Eyes Do you go to the optician regularly? Do you have any eyesight problems? Thank you for completing this form. Please bring it with you to the health check appointment. 9
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