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GP Pathfinder Clinics
at Hazeldene Medical Centre,
Crest, Eagle Eye and
Chamberlayne Road Surgery

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Alcohol Questionnaire for Adults

This is the easiest way to make a complaint or leave a comment for us.

Alcohol Questionnaire for Adults

This is the easiest way to make a complaint or leave a comment for us.

Your contact details

Title:

First name:(Required)

Last name:(Required)

Date of birth:(Required)

DD slash MM slash YYYY

Email(Required)

Home phone:(Required)

Work phone:(Required)

Mobile phone:(Required)

Home address:(Required)

Alcohol

How often do you have a drink containing alcohol?

How many standard drinks containing alcohol do you have on a typical day?

MEN: How often do you have EIGHT or more drinks on one occasion?

WOMEN: How often do you have SIX or more drinks on one occasion?

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits.
1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units.

Are You A Carer?

Do you look after a family member or friend who is unwell, disabled or frail?

Are You A Carer?

Do you look after a family member or friend who is unwell, disabled or frail?

If so please complete this form. Once you are added to our list of carers we will know about your busy life as a carer, which can affect your health. We can also try and be flexible with appointments etc as we will know about your commitments.

Carer details

Title:

First name:(Required)

Last name(s):(Required)

Address:(Required)

Postcode:

Date of birth:(Required)

DD slash MM slash YYYY

Telephone:(Required)

Email

Details of Person Being Cared For

Title:

First name:

Last name(s):

Address:

Postcode:

Date of birth:

DD slash MM slash YYYY

What relation is the person you care for?

Is the person you care for a patient at NHS GP?

Yes

No

Registering with a GP surgery outside the area you live?

You do not need to register with a GP surgery in the area you live.

Registering with a GP surgery outside the area you live?

You do not need to register with a GP surgery in the area you live.

You can register with a surgery that's more convenient, for example closer to your work or your children's school..

The GP surgery can refuse registration for reasons such as they are not taking new patients or it's too far away from your home and you need home visits.

Your details

Title:

First name:(Required)

Last name(s):(Required)

Address:(Required)

Postcode:

Date of birth:(Required)

DD slash MM slash YYYY

Mobile(Required)

Email(Required)

Reason for registering with our practice in London

Do any of the following reasons for London GP Registration apply?(Required)

Terms of Registering with GP far away from home.

The surgery will decide if they can accept you as a regular patient or accept you without home visits.

Because of the distance to your home, the GP surgery might not be able to offer home visits.

If you are not well enough to go to the GP surgery, other arrangements might be made.

Registering with a practice further away from home can affect decisions about referrals for hospital tests and treatment, or access to community health services

Additionally the offer of Cancer Screen Services and practice based Blood Tests and Investigations maybe a long distance for you to travel

Do you accept the Terms of Registering with a GP far away from home?

Do you accept the Terms of Registering with a GP far away from home?(Required)

Request to Register for Online Services

Your details

First name:(Required)

Last name:(Required)

Date of birth:(Required)

DD slash MM slash YYYY

Postcode:

Home tel::(Required)

Mobile:

Email

Find Clinic Register Online

Home
Prescriptions &
Appointments
Online Clinical Services
Students

Alperton

The Eagle Eye Surgery

26 Eagle Road
HAO 4SH

Phone: 020 8902 8223

Queen’s Park

Chamberlayne Rd Surgery

124 Chamberlayne Road
NW10 3JP

Phone: 020 8206 6590

Willesden

Crest Medical Centre

157 Crest Road
NW2 7

Phone: 020 8452 5155

Wembley

Hazeldene Medical Centre

1b Wyld Way
HA9 6PW

Phone: 020 8902 4792

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lifestyle-Form

Change of Contact Details

Title(Required)

First Name(s)(Required)

Surname:(Required)

Sex(Required)

Female

Male

Date of Birth

DD slash MM slash YYYY

Previous Surname

NHS No

Email:(Required)

Old Address

Old Postcode(Required)

Old Home Tel(Required)

New Address(Required)

New Postcode

New Tel(Required)

Mobile

Work Tel

Are you a student?(Required)

I am NOT a student

I AM a student

Other members of your family requiring a change of address (if registered here)

Comments and Suggestions Form

This is the easiest way to make a complaint or leave a comment for us.

What kind of comment would you like to send? Remember this form is not for medical matters.

Your comment is:

A suggestion

Praise

Regarding a problem

Other

What would you like to say? Enter your comments in the space below

Your contact details

Your name:

Your email:

Your telephone number:

Do you agree to be contacted regarding this matter?(Required)

Yes, I agree that the practice may contact me regarding this matter

Sick Note Request form

Requesting Fit Note (Med3)

The more information you put in this form, the more opportunity we have to help you with your Fit note request

Your details:

Title:

Date of birth:(Required)

DD slash MM slash YYYY

First name:(Required)

Surname:(Required)

Email:(Required)

Postcode:(Required)

Telephone:(Required)

The next part of this form, is you opportunity to clarify why you are asking for a fit note.

Medical reason for sick note request:(Required)

Proposed Fit Note Start Date(Required)

DD slash MM slash YYYY

Proposed Fit Note End Date(Required)

DD slash MM slash YYYY

Why do you feel that your medical condition stops you from working?(Required)

What investigations/treatment have you been doing/taking for the above medical condition?(Required)

What evidence do you have from your specialist specifying that you cannot work?(Required)

Please email any supporting documents to docman.e84066@nhs.net

CAPTCHA

Alcohol Questionnaire for Adults

This is the easiest way to make a complaint or leave a comment for us.

Alcohol Questionnaire for Adults

This is the easiest way to make a complaint or leave a comment for us.

Your contact details

Title:

First name:(Required)

Last name:(Required)

Date of birth:(Required)

DD slash MM slash YYYY

Email(Required)

Home phone:(Required)

Work phone:(Required)

Mobile phone:(Required)

Home address:(Required)

Alcohol

How often do you have a drink containing alcohol?

How many standard drinks containing alcohol do you have on a typical day?

MEN: How often do you have EIGHT or more drinks on one occasion?

WOMEN: How often do you have SIX or more drinks on one occasion?

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits.
1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units.

Application to Register with a General Medical Practitioner

Patient's Details

Please complete the text boxes and tick where appropriate

Title:

Surname:(Required)

Previous surname:

First Name(s):(Required)

Birth country:(Required)

Birth town:(Required)

Home address:(Required)

Postcode:(Required)

Telephone:(Required)

Date of birth:(Required)

DD slash MM slash YYYY

NHS Number:

Sex:

Male

Female

I am a student at:

Patient's Details

Your previous address:

Name and address of previous GP while at previous address:

If you are from abroad

Your first UK address where registered with a GP:

If previously resident in UK, date of leaving

MM slash DD slash YYYY

Date you first came to live in UK

MM slash DD slash YYYY

If you are returning from the armed forces

Address before enlisting:

Service/Personnel No.

Enlistment date:

DD slash MM slash YYYY

If you are registering a child under 5

I wish the child above to be registered with the named doctor for Child Health Surveillance

If you need your doctor to dispense medicines and appliances

I live more than 1 mile in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

Signature of patient

Signature on behalf of patient

Date:

DD slash MM slash YYYY

NHS Organ Donor Registration

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply:

Any of my organs or

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

Any part of my body

NHS Blood Donor Registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

Tick here if you have given blood in the last 3 years

For more information, please ask for the leaflet on joining the NHS Blood Donor Register Preferred address for donation: (if different from above, e.g. place of work)

Postcode:

Supplementary questions

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

Anybody in England can register with a GP practice and receive free medical care from that practice. However, if you are not 'ordinarily resident' in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of 'indefinite leave to remain' in the UK. Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges. More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice. You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment. The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

Please tick one of the following boxes:

I understand that I may need to pay for NHS treatment outside of the GP practice

I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge ('the Surcharge'), when accompanied by a valid visa. I can provide documents to support this when requested

I do not know my chargeable status

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.(Required)

Are you a parent or guardian, filling out this form on behalf of a child under 16?

Name parent or guardian:

Relationship to patient:

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC)/S1, you may be billed for the cost of any treatment received outside the GP practice, including at hospital).

Do you have a non-UK EHIC or PRC?

Yes

No

If yes, please enter details from your EHIC or PRC below:

Name:

Given names:

Date of birth:

DD slash MM slash YYYY

Personal Identification Number:

Country code:

Expiry date:

DD slash MM slash YYYY

Identification number of the institution:

Identification number of the card:

PRC validity period

From:

DD slash MM slash YYYY

To:

DD slash MM slash YYYY

Untitled(Required)

Please tick if you have an S1 (e.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state) Please give your S1 form to the practice staff.

How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Are You A Carer?

Do you look after a family member or friend who is unwell, disabled or frail?

Are You A Carer?

Do you look after a family member or friend who is unwell, disabled or frail?

If so please complete this form. Once you are added to our list of carers we will know about your busy life as a carer, which can affect your health. We can also try and be flexible with appointments etc as we will know about your commitments.

Carer details

Title:

First name:(Required)

Last name(s):(Required)

Address:(Required)

Postcode:

Date of birth:(Required)

DD slash MM slash YYYY

Telephone:(Required)

Email

Details of Person Being Cared For

Title:

First name:

Last name(s):

Address:

Postcode:

Date of birth:

DD slash MM slash YYYY

What relation is the person you care for?

Is the person you care for a patient at NHS GP?

Yes

No

Asthma Annual Review Questionnaire

Contact details

Name:(Required)

Date of birth:(Required)

DD slash MM slash YYYY

Home phone:(Required)

Mobile phone:(Required)

Email:(Required)

Postcode

Home address:(Required)

Questionnaire

1. When was your asthma diagnosed?

2. In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)?

Details of sleeping difficulties:

3. In the last month, have you had your usual asthma symptoms during the day? (cough, wheeze, chest tightness or breathlessness)?

Details of symptoms during the day:

4. How often do you use your blue inhaler?

Details of inhaler use:

5. In the last month has your asthma interfered with your usual activities (e.g. housework, work, school etc)?

Yes

No

6. Have you ever had your peak flow measured at the surgery?

Yes

No

If yes, do you know your best PEFR value

7. Are you happy with your inhaler technique?

Yes

No

If you are not, did you know there is an online demonstration on the Asthma UK website or you could pop in and see our practice nurse for more advice.

8. Have you ever smoked?

Yes

No

If 'Yes', please answer the following:

Do you smoke now?

Yes

No

If 'Yes' how many do you smoke each day?

If 'No' when did you quit?

There are plenty of options available to help you quit. Is this something you would like us to contact you about?

Yes

No

Change of Contact Details

Title(Required)

First Name(s)(Required)

Surname:(Required)

Sex(Required)

Female

Male

Date of Birth

DD slash MM slash YYYY

Previous Surname

NHS No

Email:(Required)

Old Address

Old Postcode(Required)

Old Home Tel(Required)

New Address(Required)

New Postcode

New Tel(Required)

Mobile

Work Tel

Are you a student?(Required)

I am NOT a student

I AM a student

Other members of your family requiring a change of address (if registered here)

Comments and Suggestions Form

This is the easiest way to make a complaint or leave a comment for us.

What kind of comment would you like to send? Remember this form is not for medical matters.

Your comment is:

A suggestion

Praise

Regarding a problem

Other

What would you like to say? Enter your comments in the space below

Your contact details

Your name:

Your email:

Your telephone number:

Do you agree to be contacted regarding this matter?(Required)

Yes, I agree that the practice may contact me regarding this matter

Advice in your region

England | Scotland | Wales | Northern Ireland | Ireland

Get the latest NHS information and advice about coronavirus (COVID-19).

Check if you or your child has coronavirus symptoms

Find out about the main symptoms of coronavirus and what to do if you have them.

Self-isolation and treatment if you have coronavirus symptoms

Advice about staying at home (self-isolation) and treatment for you and anyone you live with.

Testing and tracing

Information about testing for coronavirus and what to do if you're contacted by the NHS Test and Trace service.

People at high risk

Advice for people at higher risk from coronavirus, including older people, people with health conditions and pregnant women.

Social distancing and changes to everyday life

Advice about avoiding close contact with other people (social distancing), looking after your wellbeing and using the NHS and other services during coronavirus.

GOV.UK: coronavirus – guidance and support

Government information and advice.

New Patient Health Questionnaire for Adults

Your contact details

Title:

Mr.

Mrs.

Miss.

Ms.

First name:(Required)

Surname(s):(Required)

Previous surname

Occupation:

Date of birth:(Required)

DD slash MM slash YYYY

Address:(Required)

Postcode:

Email:

Telephone:(Required)

Work tel:

Mobile:

Information about you

What is your height?(Required)

What is your weight?(Required)

What is your first language?(Required)

Do you need an interpreter?(Required)

Yes

No

Ethnic Group

If other, please specify

Previous GP

Name and Address of Previous GP

Proof of Identity and Address Provided

Birth Certificate

Driving Licence

Passport

Utility Bill

Allowance Book

Solicitor's Letter

Offer of Tenancy

Other

Medical Information

Please list any serious illnesses / operations / accidents / disabilities (and for women any pregnancy related problems) and the year they took place:

Have you ever suffered from? (tick as appropriate)

Epilepsy

Yes

No

Heart Attack/Stroke

Yes

No

High Blood Pressure

Yes

No

Cancer

Yes

No

Eczema/Hay Fever

Yes

No

Blindness/Glaucoma

Yes

No

Diabetes

Yes

No

Depression

Yes

No

Asthma

Yes

No

COPD

Yes

No

If yes, please state the year(s) when were you first diagnosed?

Please list any medicines being taken and the amount:

Are you registered disabled?

Yes

No

If yes, please give details:

Have you ever refused treatment/screening of any kind?

Yes

No

If yes, please give details:

Are you allergic to any medicines?

Yes

No

If so, what and when?

Have you ever suffered from? (tick as appropriate)

Anxiety

Yes

No

Depression

Yes

No

OCD

Yes

No

Bipolar Disorder

Yes

No

If yes to any of these, please state the year(s) when were you first diagnosed?

Do you have any other mental health issues? (If yes please give details)

Are you receiving or have you received any treatment or therapy? (If yes please give details of your care and when you received it)

Carers

Do you have a carer?

Yes

No

If yes please give details:

Are you a carer?

Yes

No

If yes please give details:

Wills

Do you hold a Living Will?

Yes

No

(A Living Will is documentation regarding your personal wishes in respect of medical intervention at the time of serious illness)

Women

Have you ever had a cervical smear?

Yes

No

If 'yes', please state when, where and the result:

Smoking

Do you smoke?

Yes

No

If 'No', have you ever smoked?

Yes

No

Would you like advice on giving up smoking?

Yes

No

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?

Alcohol

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits

MEN: How often do you have EIGHT or more drinks on one occasion?

WOMEN: How often do you have SIX or more drinks on one occasion?

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

How often during the last year have you failed to do what was normally expected of you because of drinking?

In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?

Family History

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer.

Next of Kin

Please give name, address, telephone number and relationship of next of kin:

Contacting you

Have you had a flu vaccination? Enter date or 'never':

Have you had a pneumococcal vaccination? Enter date or 'never'

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Untitled(Required)

I agree that I may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders.

Registering with a GP surgery outside the area you live?

You do not need to register with a GP surgery in the area you live.

Registering with a GP surgery outside the area you live?

You do not need to register with a GP surgery in the area you live.

You can register with a surgery that's more convenient, for example closer to your work or your children's school..

The GP surgery can refuse registration for reasons such as they are not taking new patients or it's too far away from your home and you need home visits.

Your details

Title:

First name:(Required)

Last name(s):(Required)

Address:(Required)

Postcode:

Date of birth:(Required)

DD slash MM slash YYYY

Mobile(Required)

Email(Required)

Reason for registering with our practice in London

Do any of the following reasons for London GP Registration apply?(Required)

Terms of Registering with GP far away from home.

The surgery will decide if they can accept you as a regular patient or accept you without home visits.

Because of the distance to your home, the GP surgery might not be able to offer home visits.

If you are not well enough to go to the GP surgery, other arrangements might be made.

Registering with a practice further away from home can affect decisions about referrals for hospital tests and treatment, or access to community health services

Additionally the offer of Cancer Screen Services and practice based Blood Tests and Investigations maybe a long distance for you to travel

Do you accept the Terms of Registering with a GP far away from home?

Do you accept the Terms of Registering with a GP far away from home?(Required)

Repeat Prescription Request Form

Patient 1 details

Full name:(Required)

Date of birth:(Required)

DD slash MM slash YYYY

Email:

Daytime tel:(Required)

Patient ID:(Required)

Your Doctor:

Collect from:

You may request up to twenty separate items. Enter each drug and strength on your prescription. Untick the 'Required' box if you do not require the item this time. Please note that items will only be dispensed if they are included on your repeat prescription and a medication review is not pending

Drug

Untitled

Required

Drug

Untitled

Required

Drug

Untitled

Required

Drug

Untitled

Required

Drug

Untitled

Required

Drug

Untitled

Required

Drug

Untitled

Required

Drug

Untitled

Required

Drug

Untitled

Required

Drug

Untitled

Required

Drug

Untitled

Required

Drug

Untitled

Required

Please do not include medical problems here - these should be discussed with your doctor

Request to Register for Online Services

Your details

First name:(Required)

Last name:(Required)

Date of birth:(Required)

DD slash MM slash YYYY

Postcode:

Home tel::(Required)

Mobile:

Email

Signing Up For Patient Reference Group

If you are happy for us to contact you periodically by email please fill out all the fields below and send the completed form to us.

Your details

Title:

Date of birth:(Required)

DD slash MM slash YYYY

First name:(Required)

Surname:(Required)

Email:(Required)

Postcode:(Required)

Telephone:(Required)

The information below will help to make sure that we receive feedback from a representative sample of the patients registered at this practice.

Your Gender

Male

Female

Your Age

Under 16

17-24

25-34

35-44

45-54

55-64

65-74

75-84

Over 84

The ethnic background with which you most closely identify is:

British Group

Irish

White & Black Caribbean

White & Black African

White & Asian

Indian

Pakistani

Bangladeshi

Caribbean

African

Chinese

Any other

How would you describe how often you come to the practice?

Regularly

Occasionally

Very Rarely

The General Practice Assessment Questionnaire (GPAQ)

Firstly, please tell us the name of your usual doctor

1. In the past 12 months, how many times have you seen a doctor from your practice?

2. How do you rate the way you are treated by receptionists at your practice?

3 a) How do you rate the hours that your practice is open for appointments?

3 b) What additional hours would you like the practice to be open? (please tick all that apply)

Early morning

Good

Evenings

Weekends

None, I am satisfied

4 a) Thinking of times when you want to see a particular doctor, how quickly do you usually get to see that doctor?

4 b) How do you rate this?

5 a) Thinking of times when you are willing to see any doctor, how quickly do you usually get seen?

5 b) How do you rate this?

6. If you need to see a GP urgently, can you normally get seen on the same day?

7. a) How long do you usually have to wait at the practice for your consultations to begin?

7 b) How do rate this?

8 a) Thinking of times you have phoned the practice, how do you rate the ability to get through to the practice on the phone?

8 b) Ability to speak to a doctor on the phone when you have a question or need medical advice?

9 a) In general, how often do you see your usual doctor?

9 b) How do you rate this?

10 a) Thinking about when you consult your doctor, how thoroughly the doctor asked about your symptoms and how you are feeling?

10 b) How well the doctor listens to what you had to say?

10 c) How well the doctor puts you at ease during your physical examination?

10 d) How much the doctor involves you in decisions about your care?

10 e) How well the doctor explains your problems or any treatment that you need?

10 f) The amount of time your doctor spends with you?

10 g) The doctor's patience with your questions or worries?

10 h) The doctor's caring and concern for you?

11) Have you seen a nurse from your practice in the past 12 months?

12 a) Thinking about the nurse(s) you have seen, how do you rate the following: How well they listen to what you say?

12 b) The quality of care they provide?

12 c) How well they explain your health problems or any treatment that you need?

13) Are you:

14) How old are you?

15) Do you have any long-standing illness, disability or infirmity? By long-standing we mean anything that has troubled you over a period of time or that is likely to affect you over a period of time.

16) Which ethnic group do you belong to?

17) Is your accommodation?

18) Which of the following best describes you?

19) We are interested in any other comments you may have. Please enter them below.

Travel Questionnaire

Personal Details

Name:(Required)

Sex:

Date of birth:(Required)

MM slash DD slash YYYY

Daytime tel:(Required)

Postcode:(Required)

Email:(Required)

Trip Dates

Trip departure:(Required)

DD slash MM slash YYYY

Trip duration:(Required)

Itinerary

Country:(Required)

Duration:(Required)

Availability of medical help:

Country:(Required)

Duration:

Availability of medical help:

Country:

Duration:

Availability of medical help:

Country:

Duration:

Availability of medical help:

Country:

Duration:

Availability of medical help:

Trip Description - please tick all appropriate boxes:

Purpose of trip:

Business

Pleasure

Other

Type of trip:

Package

Self-organised

Backpacking

Camping

Cruise ship

Trekking

Accomodation:

Hotel

Friends/family

Other

Travelling:

Alone

With friends/family

In a group

Location type:

Urban

Rural

Altitude

Activity type:

Safari

Adventure

Other

Personal medical history

List all chronic medical conditions that you have (eg. diabetes, heart or lung conditions)

If you have had a serious reaction to a vaccine in the past, which vaccine was it?

List all of your current medications (including oral contraception)

Untitled

Have you recently suffered from any infection (e.g heavy cold, flu or high temperature)?

Untitled

Does having an injection cause you to feel faint?

Untitled

Do you or any close family members have epilepsy?

Untitled

Do you have any history of mental illness including depression or anxiety?

Untitled

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Untitled

Have you taken out travel insurance?

Untitled

If you have a medical condition, have you told your insurance company about it?

Untitled

Are you pregnant, planning pregnancy or breast feeding?

Write below any further information that might be relevant

Have you ever had any of the following vaccinations / tablets and if so, when?

Tetanus

Polio

Diptheria

Typhoid

Hepatitis A

Hepatitis B

Meningitis

Yellow Fever

Influenza

Rabies

Jap B Enceph

Tick Borne

Malaria tablets

Other

Your Accessibility Needs

We want to get better at communicating with our patients. We want to make sure you can read and understand the information we send you. If you find it hard to read our letters or if you need someone to support you at appointments, please let us know.

Your Details

Title

Date Of Birth(Required)

DD slash MM slash YYYY

First name:(Required)

Surname:(Required)

Home address:(Required)

Postcode:(Required)

Home tel:(Required)

Please tell us what communication requirements you have (eg. braile, large print, etc)

Sick Note Request form

Requesting Fit Note (Med3)

The more information you put in this form, the more opportunity we have to help you with your Fit note request

Your details:

Title:

Date of birth:(Required)

DD slash MM slash YYYY

First name:(Required)

Surname:(Required)

Email:(Required)

Postcode:(Required)

Telephone:(Required)

The next part of this form, is you opportunity to clarify why you are asking for a fit note.

Medical reason for sick note request:(Required)

Proposed Fit Note Start Date(Required)

DD slash MM slash YYYY

Proposed Fit Note End Date(Required)

DD slash MM slash YYYY

Why do you feel that your medical condition stops you from working?(Required)

What investigations/treatment have you been doing/taking for the above medical condition?(Required)

What evidence do you have from your specialist specifying that you cannot work?(Required)

Please email any supporting documents to docman.e84066@nhs.net

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