Supplementary Questionnaire

 
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Patient's Details
Title: *
Please note, if your browser does not support standard date input please use yyyy-mm-dd
Gender at birth: *
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Health Questions
Smoking Status: *
Are you interested in advice on how to quit?: *
Have you had a blood transfusion before 1991 and not been screened for Hepatitis C?: *
If unsure please talk to your GP
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Adult Females
Please use this date format: DD/MM/YYYY.
What was the result of the cervical smear?: *
Do you use contraception?:
Please state the form of contraception: *
Please note, if your browser does not support standard date input please use yyyy-mm-dd
Please note, if your browser does not support standard date input please use yyyy-mm-dd
Are you currently Pregnant?:
Please note, if your browser does not support standard date input please use yyyy-mm-dd
Additional Questions
Does someone hold a lasting Power of Attorney for your Health and Welfare?: *

An appropriate form will be posted to you (within 28 days)

Would you like us to be able to discuss your Health and Care with anyone else?: *

You will be contacted in due course (within 28 days)

 

A fast and convenient way to book appointments, request medication and view parts of your medical record. If you wish to have online access please visit the NHS App website to create an account, if you do not already have one.

Application for online access

A fast and convenient way to book appointments, request medication and view parts of your medical record. If you wish to have online access please visit the NHS App website to create an account, if you do not already have one.

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Veteran Friendly Armed Forces veteran
friendly accredited
GP practice
QiC Dermatology - Quality in Care Programme 2024
Proud to be a Parkrun Practice