London Pathway Evaluation
|
|
|
- Rosalind Hart
- 5 years ago
- Views:
Transcription
1 Digestive Disorders Clinical Academic Unit Endoscopy Unit The Royal London Hospital Whitechapel London E1 1BB Tel: Main switchboard: The Trial Homeless people, outcomes questionnaire FOLLOW-UP Version January 2012 Formatted Note here if interpreter required: 1. Date of admission: 2. Date of questionnaire: 3. Could you tell us where you have been staying since you left hospital? 4. a. Have you been admitted to this or any other hospital since your discharge? If yes - where, for how long and number of times admitted)? YES/NO b. Have you attended any Accident and Emergency Department since discharge? If yes - where, when (or day of the week if date not known) AND how many times YES/NO 5. Approximately how many nights have you slept rough in the past 4 weeks? Signature: Page 1 of 5
2 6. Have you been in prison during the last 4 weeks? YES/NO If yes- how many nights? 7. a. Do you have any new medical problems since discharge? YES/NO If YES please list b. Is the medical problem that took you into hospital better / worse / the same compared to when you left hospital? c. Is there anything else that has changed (for better or worse) since leaving hospital? 8. a. Is your mental health better / worse / the same compared to when you left hospital? b. Have you had any new mental health problems since discharge? YES/NO If yes - what? 9. Do you have a problem with drugs and/or alcohol? YES/NO Alcohol consumption: units/day or units/ week Illicit drugs-specify: type, amount spent per day & route (IV, smoke, snort etc) Signature: Page 2 of 5
3 10. Money Please rate the following 4 questions on a scale of 1-10 On a scale of 1 to 10 please tell us how you are coping with money From 1 = No money or benefits coming in, to 10= No problems or worries about money 11. Relationships On a scale of 1 to 10 please tell us how good your relationships are From 1= no one I can trust, to 10= I have all the friends or family contacts I need 12. Drugs and alcohol On a scale of 1 to 10 please tell us about how you manage with drink and drugs From 1= 0ther people say I have problem with drugs and/or alcohol, but I don t agree, to 10= No problem with alcohol or drugs 13. Managing accommodation On a scale of 1 to 10 please tell us about your accommodation From 1= I am sleeping rough, nothing can be done, to 10= I am managing well in my own accommodation. Signature: Page 3 of 5
4 EQ-5D-5L Under each heading, please tick the ONE box that best describes your health TODAY 14. MOBILITY I have no problems in walking about I have slight problems in walking about I have moderate problems in walking about I have severe problems in walking about I am unable to walk about 15. SELF-CARE I have no problems washing or dressing myself I have slight problems washing or dressing myself I have moderate problems washing or dressing myself I have severe problems washing or dressing myself I am unable to wash or dress myself 16. USUAL ACTIVITIES (e.g. work, study, housework, family or leisure activities) I have no problems doing my usual activities I have slight problems doing my usual activities I have moderate problems doing my usual activities I have severe problems doing my usual activities I am unable to do my usual activities 17. PAIN / DISCOMFORT I have no pain or discomfort I have slight pain or discomfort I have moderate pain or discomfort I have severe pain or discomfort I have extreme pain or discomfort Signature: Page 4 of 5
5 18. ANXIETY / DEPRESSION I am not anxious or depressed I am slightly anxious or depressed I am moderately anxious or depressed I am severely anxious or depressed I am extremely anxious or depressed Signature: Page 5 of 5
London Pathway Evaluation
Digestive Disorders Clinical Academic Unit Endoscopy Unit The Royal London Hospital Whitechapel London E1 1BB Tel: 020 7377 7218 Main switchboard: 020 7377 7000 The Trial Homeless people, outcomes questionnaire
Your Health Survey. Forename: Surname: Renal Unit: Type of treatment: If HD, are you: Date of birth: Home Post Code: Date completed: NHS number:
Your Health Survey Why this questionnaire You may already have heard about renal units introducing health questionnaires. The purpose of these questionnaires is to find out how your kidney disease affects
ARTIC PC. Diagnosis & treatment study Diary. Version 1 ( )
Patient Study Number: Date of consultation: Month Year ARTIC PC Diagnosis & treatment study Diary Version 1 (09.08.16) Page 1 of 29 INSTRUCTIONS Your doctor or nurse and researchers from the ARTIC-PC study
KAISER PERMANENTE SPINE
KAISER PERMANENTE SPINE The following forms are specially designed to give your doctor valuable information about the health of your spine. The same way an EKG gives us information about your heart. It
Varicose Veins Surgery Questionnaire
REV_VaricoseVeins_12pp_Q_PostOp 29/10/09 Page 1 Varicose Veins Surgery Questionnaire After your operation About three months ago you had a Varicose Veins Operation. You may remember that you agreed that
Good. Poor [ ] [ ] Yes, at all [ A ] Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf [ ] [ ]
![Good. Poor [ ] [ ] Yes, at all [ A ] Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf [ ] [ ]](/thumbs/96/126804246.jpg "Good. Poor [ ] [ ] Yes, at all [ A ] Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf [ ] [ ]")
PATIENT I.D. This survey asks for your views about your health. This information will help keep track of how you feel and how well you are able to do your usual activities. For each of the following questions,
The Socioeconomic Cost of Chronic Rhinosinusitis (SoCCoR) Study
UEA Office Use only: Patient Indentification umber: Please try to fill in ALL parts of the questionnaire, even if you do not have sinus problems and do not feel they are directly relevant to you. The Socioeconomic
A trial to evaluate an extended rehabilitation service for stroke patients (EXTRAS) PATIENT BASELINE ASSESSMENT
A trial to evaluate an extended rehabilitation service for stroke patients () PATIENT BASELINE ASSESSMENT Version 5: 11 February 2014 Patient Name: Centre Number: date: Assessor (print name): Assessor
Has Consumer Directed Care improved the quality of life of older Australians? Professor Julie Ratcliffe School of Medicine Flinders University
Has Consumer Directed Care improved the quality of life of older Australians? Professor Julie Ratcliffe School of Medicine Flinders University Acknowledgments: ARC Linkage Project A Health Economics Model
Mesothelioma Outcomes, Research and Experience survey (MORE Survey).
Mesothelioma Outcomes, Research and Experience survey (MORE Survey). Mesothelioma UK would like to invite mesothelioma patients to have the opportunity to describe what their experience of investigations,
Please return the questionnaire in the enclosed pre-paid envelope
Instructions Please complete the questionnaire, making sure you reply to all the questions. This should take you about 20 minutes. If you have difficulties completing the questionnaire, please ask someone
In order to receive the maximum benefit from your rehabilitation program, it is important to understand and comply with the following guidelines:
Arrival Policy 900 2 nd Ave., Madison, MN 56256 In order to receive the maximum benefit from your rehabilitation program, it is important to understand and comply with the following guidelines: Attend
The Socioeconomic Cost of Chronic Rhinosinusitis (SoCCoR) Study
UEA Office Use only Local Ref Please try to fill in ALL parts of the questionnaire, even if you do not have sinus problems and do not feel they are directly relevant to you. The Socioeconomic Cost of Chronic
KAISER PERMANENTE SPINE
KAISER PERMANENTE SPINE The following forms are specially designed to give your doctor valuable information about the health of your spine. The same way an EKG gives us information about your heart. It
This is a repository copy of Health-related quality of life after treatment for bladder cancer in England.
This is a repository copy of Health-related quality of life after treatment for bladder cancer in England. White Rose Research Online URL for this paper: http://eprints.whiterose.ac.uk/130368/ Version:
Please complete ALL 6 pages of the form in blue/black ink. Patient Acct # Provider # BMI # Height Weight
Please complete ALL 6 pages of the form in blue/black ink. Patient Acct # Provider # BMI # Height Weight f-25-n (08-07-13) ( 11-02-12) 0 10 Spine Questionnaire (continued) OFFICE USE ONLY Patient Acct
R Number. Patient Intake
Date: dd/mm/yy Patient Information Name: OHIP #: Female Male Age: Date of Birth: dd/mm/yy Phone: Address: Email: City: Postal Code: What is your current marital status? Married Common-law Single (never
Neuropathic pain (pain due to nerve damage)
Neuropathic pain (pain due to nerve damage) Clinical Guideline Pain can be nociceptive, neuropathic or mixed. The neuropathic component of pain generally responds poorly to conventional analgesics. Consider
Patient Details Hidden. Clinical Enrollment. Quality of Life. EuroQOL (EQ-5D) Enroll Patient. Not Started. Not Started
Patient Details Hidden Show Patient Clinical Enrollment t Started Quality of Life t Started EuroQOL (EQ-5D) Did the patient complete a EuroQOL form? Please select a reason why the EuroQOL was not completed:
DATA COLLECTION SHEET CRF 3M FOLLOW UP AT 3 MONTHS (+/- 2 weeks)
DATA COLLECTION SHEET CRF 3M FOLLOW UP AT 3 MONTHS (+/- 2 weeks) Center ID: Patient code: Date of evaluation (dd/mm/yyyy): / / 90 day mortality No Yes Date of death (dd/mm/yyyy): / / (If Yes specify cause
Enhanced Recovery After Surgery (ERAS) Cystectomy. Patient Diary
Enhanced Recovery After Surgery (ERAS) Cystectomy Patient Diary page 2 Introduction Enhanced Recovery is a new way of improving the experience and well-being of people who need major surgery. It will help
Welcome to NHS Highland Pain Management Service
Welcome to NHS Highland Pain Management Service Information from this questionnaire helps us to understand your pain problem better. It is important that you read each question carefully and answer as
How can clinical psychologists help with chronic pain?
University Teaching Trust How can clinical psychologists help with chronic pain? Irving Building Pain Centre 0161 206 4002 All Rights Reserved 2017. Document for issue as handout. Why have you been referred
Enhanced Recovery After Surgery (ERAS) Diary
Cardiac Surgery Enhanced Recovery After Surgery (ERAS) Diary Patient s Name: Options available If you d like a large print, audio, Braille or a translated version of this leaflet then please call: 01253
Wisconsin Quality of Life Caregiver Questionnaire Wisconsin Quality of Life Associates University of Wisconsin - Madison.
Wisconsin Quality of Life Caregiver Questionnaire Wisconsin Quality of Life Associates University of Wisconsin - Madison Interview Information: Your Name: ID#: Date of Completion: / / Age: Sex: Relationship
Session 6: Choosing and using HRQoL measures vs Multi-Attribute Utility Instruments QLU-C10D and EQ-5D as examples
Session 6: Choosing and using HRQoL measures vs Multi-Attribute Utility Instruments QLU-C10D and EQ-5D as examples - Madeleine King & Richard De Abreu Lourenco- Overview Learning Objectives To discuss
QOLRAD QUESTIONNAIRE FOR PATIENTS WITH GASTROINTESTINAL SYMPTOMS PLEASE READ THIS CAREFULLY BEFORE ANSWERING THE QUESTIONS
QOLRAD QUESTIONNAIRE FOR PATIENTS WITH GASTROINTESTINAL SYMPTOMS PLEASE READ THIS CAREFULLY BEFORE ANSWERING THE QUESTIONS On the following pages you will find some questions asking about how you have
MOTOR VEHICLE ACCIDENT PAIN CHART
MOTOR VEHICLE ACCIDENT PAIN CHART Name Today s Date (D/M/Y) Area of Concern What is the WORST pain you have ever experienced? (other than the pain you are experiencing NOW!) What was the date of this painful
<</<</<<<< <</<</<<<< < << <<< * * *1* *TCO26* ! No Surgery or Treatment Scheduled Yet
Cervical Myelopathy Pre-Treatment Form - Twin Cities Orthopedics STICKER FIELD If there is not any sticker available please write the required data below: Patient First Name: Patient Last Name: Medical
Extended Aberdeen Spine Pain Scale
Extended Aberdeen Spine Pain Scale SECTION A Please answer the following questions 1. In the last two weeks, how many days did you suffer pain in the neck, back or limbs? (Please tick one box) None at
Understanding dementia. people with learning disabilities finding out and raising awareness together
Understanding dementia people with learning disabilities finding out and raising awareness together About this booklet This booklet will tell you about dementia. It will also help you to understand what
Non Arthroplasty Hip Surgery Register (NAHR) Patient Consent Form
The Non Arthroplasty Hip Surgery Register (NAHR) Patient Sticker The British Hip Society 35-43 Lincoln s Inn Fields, London WC2A 3PN www.britishhipsociety.com/nahr Non Arthroplasty Hip Surgery Register
Patient Follow-up Form - Version 1.1
Physician: [Last Name GO PROJECT Patient Follow-up Form - Version 1.1 Thank you for participating in the Glioma Outcomes Project. To continue participating in this important project, complete or correct
IS THE GOVERNMENT DOING ENOUGH TO PREVENT HOMELESSNESS?
IS THE GOVERNMENT DOING ENOUGH TO PREVENT HOMELESSNESS? THE DILEMMA The homeless problem in Britain is getting worse. Since 2010, the number of people sleeping rough in England has risen every year. An
DALLAS SLEEP SURVEY. Sleep Habits & Challenges of Dallas-Area Residents
2018 DALLAS SLEEP SURVEY Sleep Habits & Challenges of Dallas-Area Residents EXECUTIVE SUMMARY It is well-researched and widely accepted that sleep is a major contributing factor to overall health and wellness.
LABs Albumin. (g/dl) Haemoglobin, (g/l) Creatinin, (mg/dl)
DATA COLLECTION SHEET CRF B Baseline evaluation Center ID: Patient code: Date of birth (dd/mm/yyyy): / / Sex: Male Female Living situation: home independent home with family/care giver residential care
Dorset Homeless Health Needs Audit Results 2017
Dorset Homeless Health Needs Audit Results 2017 These are some of the faces of homelessness Homelessness and Health The homeless population s life expectancy is half that of the general population, equating
Vulnerable Adults Housing & Well-Being Support. Easy Read Version Consultation Questionnaire
Vulnerable Adults Housing & Well-Being Support Easy Read Version Consultation Questionnaire We want to know what is really important to Vulnerable Adults. We want to know what support is needed to make
Medical History. Instructions. My telephone number is: 1 Tools Medical History
Medical History Instructions To do the best possible job with your pain, your doctor needs details about your history, including current and past medical problems, medications, health habits, and family
For each question you will be asked to fill in a bubble in each line: 1. How strongly do you agree or disagree with each of the following statements?
Appendix A: SF-36 Version 2 (modified for Australian use*) The SF-36v2 Health Survey Instructions for Completing the Questionnaire Please answer every question. Some questions may look like others, but
ANNUAL FOLLOW-UP QUESTIONNAIRE
SLEEP HEART HEALTH STUDY - TUCSON ANNUAL FOLLOW-UP QUESTIONNAIRE - 2004 Dear Sleep Heart Health Study participant: Today s Date: / / Month Day Year Please take the time to complete and return this short
NAME OF PATIENT: STREET ADDRESS: CITY: STATE: ZIP: SEX: Male Female AGE: BIRTHDATE: MARITAL STATUS: PATIENT EMPLOYED BY: BUSINESS ADDRESS:
DATE: HOME PHONE: NAME OF PATIENT: (Last name) (First name) (Middle) RESPONSIBLE PARTY (if a minor): STREET ADDRESS: CITY: STATE: ZIP: SEX: Male Female AGE: BIRTHDATE: MARITAL STATUS: PATIENT EMPLOYED
An Introduction to Costeffectiveness
Health Economics: An Introduction to Costeffectiveness Analysis Subhash Pokhrel, PhD Reader in Health Economics Director, Division of Health Sciences Why do we need economic evaluation? 2017 2 Patient
Having a kidney biopsy. Information for patients Sheffield Kidney Institute (Renal Unit)
Having a kidney biopsy Information for patients Sheffield Kidney Institute (Renal Unit) This leaflet is designed to answer any questions you may have about having a biopsy of your kidney. We hope that
USF Mood & Anxiety Disorders Program
QUICK INVENTORY OF DEPRESSIVE SYMPTOMATOLOGY (SELF-REPORT)(QIDS-SR16) Please circle the one response to each item that best describes you for the past seven days. 1. Falling Asleep: 0 I never take longer
SECTION 1: INCLUSION, EXCLUSION & RANDOMISATION INFORMATION
SECTION 1: INCLUSION, EXCLUSION & RANDOMISATION INFORMATION DEMOGRAPHIC INFORMATION Given name Family name Date of birth Consent date (DD/MMM/YYYY) (DD/MMM/YYYY) Gender Female Male Date of surgery (DD/MMM/YYYY)
HEALTH STATUS QUESTIONNAIRE 2.0
HEALTH STATUS QUESTIONNAIRE 2.0 Mode of Collection Self-Administered Personal Interview Telephone Interview Mail Other Patient: Date: Patient ID#: Instructions: This survey asks for your views about your
Section 4 - Dealing with Anxious Thinking
Section 4 - Dealing with Anxious Thinking How do we challenge our unhelpful thoughts? Anxiety may decrease if we closely examine how realistic and true our unhelpful/negative thoughts are. We may find
SUPPLEMENT MATERIALS. Appendix A: Cleveland Global Quality of Life (CGQL) [0 being the WORST and 10 being the BEST]
![SUPPLEMENT MATERIALS. Appendix A: Cleveland Global Quality of Life (CGQL) [0 being the WORST and 10 being the BEST]](/thumbs/73/68207476.jpg "SUPPLEMENT MATERIALS. Appendix A: Cleveland Global Quality of Life (CGQL) [0 being the WORST and 10 being the BEST]")
SUPPLEMENT MATERIALS Appendix A: Cleveland Global Quality of Life (CGQL) [0 being the WORST and 10 being the BEST] Q1. Current Quality of Life: Circle one 6 7 8 9 10 Q2. Current Quality of Health: Circle
Autism Strategy Survey 2017
We are putting together a strategy that sets out how we can help people with autism, aged 18 and over, get the services they need. We d also like to help everyone learn about autism. If you're living with
HIV in the United Kingdom
HIV in the United Kingdom Valerie Delpech and Alison Brown on behalf of the HIV and AIDS Reporting Section National Infection Service Public Health England Released 15 December 2017 Undetectable=Untransmittable
2016 Children and young people s inpatient and day case survey
NHS Patient Survey Programme 2016 Children and young people s inpatient and day case survey Technical details for analysing trust-level results Published November 2017 CQC publication Contents 1. Introduction...
Problem Situation Form for Parents
Problem Situation Form for Parents Please complete a form for each situation you notice causes your child social anxiety. 1. WHAT WAS THE SITUATION? Please describe what happened. Provide enough information
CHILDREN S HEALTH SURVEY
CHILDREN S HEALTH SURVEY FOR ASTHMA CHILD VERSION The purpose of this survey is to find out how much asthma affects the everyday life of both you and your family. THERE ARE NO RIGHT OR WRONG ANSWERS!!
Moretonhampstead Primary School PSHE, SEAL, Citizenship Curriculum
Moretonhampstead Primary School PSHE, SEAL, Citizenship Curriculum Termlets SEAL 1 New beginnings Safety Education - keeping safe indoors/ outdoors - keeping oneself safe 2 Say no to bullying Getting on
The Melbourne Shoulder Score
The Melbourne Shoulder Score Name Date Date of Birth Hand Dominance (please circle) Right Left Which shoulder is/was problematic (please circle) Right Left Both if both, please duplicate the form and fill
*521634* Sleep History Questionnaire. Name of primary care doctor:
*521634* Today s Date: Sleep History Questionnaire Appointment Date: Please answer the following questions before coming to your appointment. Please arrive 15 minutes early with this packet filled out.
PHYSICAL HEALTH ASSESSMENT TOOL
PHYSICAL HEALTH ASSESSMENT TOOL Name: General health and lifestyle Do you have any diagnosed physical health conditions? If yes, give details (include both minor and serious conditions) question If yes,
Patient Questionnaires BASELINE ASSESSMENT
Patient Questionnaires BASELINE ASSESSMENT Page 1 of 9 Section: Study Entry Patient identification number Date of study entry D D M M Y Y Y Y GP Practice Number Researcher Initials Signature of Assessor
DANCER INTAKE FORM. 9. Do you teach dance? Yes No. If yes, how many hours a week do you teach? 10. Nightly sleep: Average of hours of sleep per night
DANCER INTAKE FORM 1. What is your primary style of dance? 2. How long have you been dancing in your primary style? 3. What is your current company or dance academy/school? 4. How long have you been at
Patient Outcome Scores (pre-op)
Name: NHS No: Hospital No: DOB: Gender: Patient Outcome Scores (pre-op) Subjective Knee Evaluation Symptoms: Grade symptoms at the highest activity level at which you think you could function without significant
What does the procedure involve? What are the alternatives to this procedure? What should I expect before the procedure?...
This leaflet explains: What does the procedure involve?... 2 What are the alternatives to this procedure?... 2 What should I expect before the procedure?... 2 What happens during the procedure?... 2 What
Ipswich Locality Homelessness Partnership
Ipswich Locality Homelessness Partnership (ILHP) Briefing Paper: An introduction to homelessness and how to help people who are homeless, or at risk of this, in Ipswich. Background and introduction: Since
ANNUAL FOLLOW-UP QUESTIONNAIRE
SLEEP HEART HEALTH STUDY - TUCSON ANNUAL FOLLOW-UP QUESTIONNAIRE - 2003 Dear Sleep Heart Health Study participant: Today s Date: / / Month Day Year Please take the time to complete and return this short
Homelessness in Glasgow
Homelessness in Glasgow Survey Report June 2016 SHIEN at GHN 1 SHIEN at GHN 16a, The Adelphi Centre, 12 Commercial Road, Glasgow G5 0PQ 0141 420 7272 shien@ghn.org.uk www.ghn.org.uk /shien Te 2 Homelessness
Healthy Weight: Healthy Wales. Youth and community version
Healthy Weight: Healthy Wales Youth and community version Introduction The Welsh Government want everyone in Wales to be a healthy weight. We want people to eat healthy food and be active. We all make
Corner on Wellness Chiropractic Center Therapeutic Massage
Corner on Wellness Chiropractic Center Therapeutic Massage Patient Name Date Address _ City State Zip Phone Email Emergency Contact Name Phone Employer Work Phone Date of Birth Social Security # Is condition
Do you help look after someone in your family who is ill or has a disability? Does this cause you problems at school? Want some help?
Do you help look after someone in your family who is ill or has a disability? Does this cause you problems at school? Want some help? Who is a young carer? A young carer is a person aged between 4 and
QUALITY OF LIFE IN EPILEPSY - QOLIE-31 (Version 1.0)
QUALITY OF LIFE IN EPILEPSY - QOLIE-31 (Version 1.0) US English QOLIE-31 Copyright 1993, RAND. All rights reserved. The QOLIE-31 was developed in cooperation with Professional Postgraduate Services. Today
Personal Social Services: Adult Social Care User Survey in England Summary of Results in Peterborough
Personal Social Services: Adult Social Care User Survey in England 2017-18 Summary of Results in Peterborough Introduction This report contains findings from the Adult Social Care Survey 2017-18. This
Workshop cases answers
Workshop cases answers BPSD Workshop: case histories Case 1: Mrs DM Scenario This is an 83 year old lady diagnosed with multi infarct dementia in 2008. Lives with husband and the couple are supported by
Hard Edges Scotland: Lived Experience Reference Group
Hard Edges Scotland: Lived Experience Reference Group May 2017 1. Lived Experience Reference Group: Role and Membership 1.1 The Lived Experience Reference Group was established as a core part of the Hard
o never o 1 day per week or less o 2-3 days per week o 4-6 days per week o every day
Quality of Life Questionnaire Qualeffo-41 (10 December 1997) Users of this questionnaire (and all authorized translations) must adhere to the user agreement. Please use the related Scoring Algorithm. A
USE THE LETTERS LISTED BELOW TO INDICATE
USE THE LETTERS LISTED BELOW TO INDICATE THE TYPE AND LOCATION OF YOUR PAIN & SENSATIONS A = ACHE B = BURNING S = STABBING N = NUMBNESS P = PINS & NEEDLES O = OTHER COMMENTS: COMMENTS: PT INITIALS DATE
Northumbria Healthcare NHS Foundation Trust. Emotional changes in pregnancy and after childbirth. Issued by the Maternity Department
Northumbria Healthcare NHS Foundation Trust Emotional changes in pregnancy and after childbirth Issued by the Maternity Department How can pregnancy affect my mental health? Women can experience problems
Exercise. Good Weight A PT E R. Staying Healthy
Eat Healthy Foods Keep at a Good Weight Exercise Don t Smoke Get Regular Checkups Take Care of Stress A PT E R CH Staying Healthy 6 81 How Can I Stay Healthy? You can do many things to prevent poor health
My life, My choices. Telling people what matters to me at the end of my life.
My life, My choices Telling people what matters to me at the end of my life. I don t want to put it to the back of my mind. In fact it s at the front of my mind. It makes me make the most of life Why bother?
Focus on... arthrosis. focus health
Focus on... arthrosis focus health Arthrosis is the most common pathology in the second half of life 2 LET S DO SOME CLARITY Arthrosis (or osteoarthrosis) and arthritis are terms often considered synonymous,
CONSENT FORM UROLOGICAL SURGERY
CONSENT FORM for UROLOGICAL SURGERY (Designed in compliance with consent form 1) PATIENT AGREEMENT TO INVESTIGATION OR TREATMENT Patient Details or pre-printed label Patient s NHS Number or Hospital number
Interview Team: INTERVIEW QUESTIONNAIRE: Teenage Sleep Clinic
Interview Team: Date: INTERVIEW QUESTIONNAIRE: Teenage Sleep Clinic The aim of this questionnaire is to learn more about you, your habits, and your sleep. This will help us to understand about the problems
Smoking and Quitting Assessment
Smoking and Quitting Assessment A. Which of the following describes you? q I m not interested in trying to quit smoking. q I know I need to quit smoking, but I m not quite ready yet. q I m ready to quit
Initial Patient Questionnaire
Insert service name and logo here Initial Patient Questionnaire Section 1 Patient information Title: Family name (surname): Given name(s): Mr Mrs Ms Miss Gender: Male Female Date of birth: / / Today s
Parenting Your Teen in 2016
Parenting Your Teen in 2016 Overview Peer Pressure Family Pressure Depression Coping Mechanisms Peer Pressure 1. What is peer pressure 2. Who is affected by peer pressure? 3. In what ways are teens pressured
Cardiff Cardiac Ablation PROM (C-CAP2)
Arrhythmia Questionnaire After your Operation We would be grateful if you could give us some feedback on how you have been feeling since your procedure to treat your palpitations / fast or irregular heartbeats.
CYSTOSCOPY AND URETHRAL BULKING INJECTIONS INFORMATION FOR PATIENTS
The British Association of Urological Surgeons 35-43 Lincoln s Inn Fields London WC2A 3PE Phone: Fax: Website: E-mail: +44 (0)20 7869 6950 +44 (0)20 7404 5048 www.baus.org.uk admin@baus.org.uk CYSTOSCOPY
handouts for women 1. Self-test for depression symptoms in pregnancy and postpartum Edinburgh postnatal depression scale (epds) 2
handouts for women 1. Self-test for depression symptoms in pregnancy and postpartum Edinburgh postnatal depression scale (epds) 2 2. The Cognitive-Behaviour Therapy model of depression 4 3. Goal setting
Worker s Compensation Form
Worker s Compensation Form Patient Name: Today s Date: Patient Address: Patient Phone Number: ( ) Cell: ( ) Patient Date of Birth Occupation: Male Female SSN: - - Name of Employer: Contact Person: Address:
Medicare Wellness Visit
of Birth: Today s : Medicare Wellness Visit Dear Patient, Your Medicare benefits include an Annual Wellness Visit to assist in preventing illness or detect illness at an early stage. Your Annual Wellness
TB the disease, its treatment. Tuberculosis. and prevention
TB the disease, its treatment Tuberculosis and prevention TUBERCULOSIS TB (tuberculosis) is an infectious disease that usually affects the lungs, although it can affect any part of the body. About 150
Heritage Chiropractic Clinic Geoffrey A. Sandels, D.C Lenora Church Road / Snellville, Georgia / Welcome to our office!
Heritage Chiropractic Clinic Geoffrey A. Sandels, D.C. 2407 Lenora Church Road / Snellville, Georgia 30078-6916 / 770-979-2731 Welcome to our office! Today's Date: / / Your Name: [ ] Male [ ] Female What
Department of Vascular Surgery Femoral-Popliteal and Femoral-Distal Bypass Grafts
Department of Vascular Surgery Femoral-Popliteal and Femoral-Distal Bypass Grafts Why do you need the operation? You need this operation because you have either pain in your legs or a leg ulcer or gangrene
Worcestershire Dementia Strategy
Worcestershire Dementia Strategy An Easy Read Summary Introduction This is a plan about how we will support people with dementia, their families and carers in Worcestershire. This is called the Worcestershire
PERSONAL INJURY QUESTIONNAIRE
PERSONAL INJURY QUESTIONNAIRE Name Date of Birth Age Address City State Zip NATURE OF ACCIDENT: 1. Date of Accident Time of Day (AM / PM) 2. Please state how the accident happened in your own words: 3.
Occupational therapy after stroke
Call the Stroke Helpline: 0303 3033 100 or email: info@stroke.org.uk Occupational therapy after stroke This guide explains how occupational therapy can help your recovery and rehabilitation after a stroke.
BOTHELL INTEGRATED HEALTH, LLC Therapeutic Massage
BOTHELL INTEGRATED HEALTH, LLC Therapeutic Massage Patient Name Date Address City State Zip Phone (home) (cell) Emergency Contact Name Phone Employer Date of Birth Work Phone Social Security # Is condition
These questionnaires are used by psychology services to help us understand how people feel. One questionnaire measures how sad people feel.
ADAPTED PHQ-9 & GAD-7 QUESTIONNAIRES How to fill in these questionnaires: These questionnaires are used by psychology services to help us understand how people feel. One questionnaire measures how sad
REMOVAL OF PART OR ALL OF THE EPIDIDYMIS
Procedure Specific Information What is the evidence base for this information? This publication includes advice from consensus panels, the British Association of Urological Surgeons, the Department of
The Rivermead Post-Concussion Symptoms Questionnaire*
The Rivermead Post-Concussion Symptoms Questionnaire* After a head injury or accident some people experience symptoms which can cause worry or be a nuisance. We would like to know if you know if you now
Strong bones after 50 Fracture liaison services explained A guide for patients, carers and families
Strong bones after 50 Fracture liaison services explained A guide for patients, carers and families What the NHS should provide for people over 50 who have broken a bone after falling from standing height
Lifestyle/Readiness for Change Assessment
Lifestyle/Readiness for Change Assessment This form asks you a variety of questions about your lifestyle habits. This questionnaire should take about 10 minutes. Fill in the information requested, or place