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

Similar documents
MEDICAL QUESTIONNAIRE (female)

Teaching NHS Trust. My Health Record. keyworker. Learning Disability Service

MEDICAL QUESTIONNAIRE (male)

Amarillo Surgical Group Doctor: Date:

SANTA MONICA BREAST CENTER INTAKE FORM

Margie Petersen Breast Center

John Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter

Bevacizumab (Avastin ) treatment for Neurofibromatosis Type 2 (NF2) Information for patients

Medical History Form

Welcome to About Women by Women

DANA COKER KINGDON, PA

Please list all medications you are currently taking (include aspirin, vitamins, hormones), Dosage, and Frequency.

CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)

PATIENT HEALTH HISTORY

Johanna M. Hoeller, DC PS

CHIROPRACTIC ASSOCIATES CLINIC

SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET

N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro

Health screening questionnaire

Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?

For the Patient: LUAVPG (Carboplatin Option)

HEALTH INFORMATION FORM

FIRST TIME VISIT APPOINTMENT CHECKLIST Department of Radiation Oncology 200 Medical Plaza, Ste B265 Los Angeles, CA

Patient Information Leaflet Number: CC 041 v2

For the Patient: Cyclosporine injection Other names: SANDIMMUNE I.V.

Be cancer aware Patient Information

Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?

MEDICAL DATA SHEET For Patients 18 years of age and older

Enquiry Severity Immediate or other. Joint or muscle pain - any part of the body. Abdominal pain Acute Non-acute. Acne Anxiety Acute Non-acute

Ibrutinib (Imbruvica )

MEDICAL HISTORY RECORD

Symptom Review (page 1) Name Date

Medical Questionnaire

Integrative Consult Patient Background Form

BIRMINGHAM VASCULAR ASSOCIATES, P.C. PATIENT MEDICAL HISTORY FORM

Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire

Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?

HISTORY PAPERWORK FOR APPOINTMENTS WITH DAVID A. PROPST, D.O.

RHEUMATOLOGY PATIENT HISTORY FORM

Patient Intake Form for Acupuncture Treatment at Infinite Healing

Patient History Form

Health Intake Form. List your top five concerns or reasons for requesting your appointment with Dr. Weiss

Laser Vein Center Thomas Wright MD RVT Page 1 of 4

Eloxatin Oxaliplatin concentrated solution for injection

Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History

Laser Vein Center Thomas Wright MD Page 1 of 4

Tummy bugs. Home: Family doctor: What to do next

Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.

CHIROPRACTIC ASSOCIATES CLINIC

PRE-VISIT QUESTIONNAIRE FOR NEW PATIENTS

PRIMARY CARE (719)

Referring Physician/Therapist. Primary Care Physician. Reason for Visit

NEW PATIENT QUESTIONNAIRE Spine pt acct #

Emotional Relationships Social Life Sexually Recreation

Johns Hopkins Hospital Division of Gastroenterology Patient Questionnaire

Where is your pain located? Please use the diagram below to indicate where most of your pain is located.

Creve Coeur Family Medicine, LLC

New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:

Name : Date of Birth : Social Security #: Age: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Address: May we leave a

GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT

CONSULTATION ADMITTANCE FORM

HD CLINIC MEDICAL HISTORY FORM

Patient Health History

Spine New Patient Questionnaire Rev

Your Name: Date of Birth: Age: Address: City/State/Zip: Phone (home): (mobile): (work): Shall we add you to our e-newsletter?

Nivolumab. Nivolumab

Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY

Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):

Adult Demographics Form

PATIENT INFORMATION FORM (WOMEN ONLY)

/ / - - / / Age: USF Cutaneous Oncology Program. Skin Cancer Questionnaire. Patient Information: Fax completed forms to:

GoPrivateMD General Information & History

PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / /

Arizona Injury Medical Associates, P.L.L.C. Physiatry Care

Southern Maine Integrative Health Center Adult Intake Form

CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:

The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.

Interventional Pain Medicine. P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C

N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro

Epirubicin. Epirubicin

Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:

Address: City: State: Zip: Home #: Cell #: Other #: Employer Address: City: State: Zip: Phone #: Sex: DOB: / / Address: Policy ID: Group ID: Employer:

What do you believe is causing your most important health concern?

Alectinib (Alecensa ) Alectinib (Alecensa )

55 S. Main Street, Driggs, ID (208)

Date of Visit / / Date of Birth / / Age

ALLERGIES: EMERGENCY CONTACTS Name Relationship to Patient Home/Cell Name Relationship to Patient Home/Cell

Questionnaire for Lipedema Patients

SOC SEC #: - - Date of Birth: - - Age: yrs. State: Zip Code: Employer:

Medical History Form

Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone

SUSQUEHANNA HEALTH CANCER CENTER HEMATOLOGY & ONCOLOGY NEW PATIENT HEALTH QUESTIONNAIRE. Name: Date of Birth:

HEALTH HISTORY QUESTIONNAIRE

Traztuzumab (Herceptin)

Oral anti-cancer treatment

PULMONARY MEDICINE PATIENT QUESTIONNAIRE

DBL Docetaxel, Concentrated Injection

Gemcitabine (Gemzar )

Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY

Transcription:

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

Are you married, single, divorced or widowed? Address:... Next of kin:...... Realation:...... Address:... Email:...... Tel:... Tel:......... 1 Medication How do you take your list medication?

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

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

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

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

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

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

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

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

Health Facilitation Team Health Action Plan www.easyonthei.nhs.uk/get-checked-out-home Name: Date of health check: Health Issue Action Needed Who will do it Review Date

Health Facilitation Team The Health Facilitation Team are available to support Health Professionals to improve and inc increase access to health for people with a Learning Disability. Should your require any FREE advice and support to help you obligation as a Health Care Provider then please contact us. The Health Facilitation Team St Mary s Hospital Willow House Green Hill Road Leeds LS12 3QE Tele: 0113 85 55049 www.easyonthei.nhs.uk/get-checked-out-resources

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback