Patient Health Questionnaire

Patient Details

First Name: *

Surname: *

Date of Birth: *

Please use date format DD/MM/YYYY

Email Address: *

Address: *

Postcode: *

Home Telephone:

Mobile Number:

Work Number:

Are you happy to receive text messages? *

Yes

No

Occupation: *

What is your gender? *

Male

Female

Indeterminate

Height (cm):

Weight (kg):

Wasit Measurement (inches):

About you

Household Members

Name:

Relationship:

Name:

Relationship:

Name:

Relationship:

Are you a carer for a friend or relative? *

Yes

No

Are you cared for by a friend or relative? *

Yes

No

Name of Carer: *

Carer's contact number: *

Special access requirement eg. vision/hearing/mobility/translator:

About your ethnic origin

Please specify: *

About your lifestyle

Date that you stopped smoking:

Please use date format DD/MM/YYYY

Are you interested in giving up smoking?

Yes

No

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol

How often do you have a drink that contains alcohol? *

How many standard alcoholic units do you have in a typical day when you are drinking? *

How often do you have six or more standard drinks on one occasion? *

About your medication history

Please list your regular medication:

Name of Drug:

Dose:

Frequency:

Name of Drug:

Dose:

Frequency:

Name of Drug:

Dose:

Frequency:

Name of Drug:

Dose:

Frequency:

Name of Drug:

Dose:

Frequency:

Do you have any allergies? *

Yes

No

Please list with details of type of reaction: *

Are you allergic to Penicillin? *

Yes

No

Any adverse drug reaction? *

Yes

No

Please give details of your nominated pharmacy:

Immunisation History

Date of your last flu injection:

Please use format DD/MM/YYYY

Please give any immunisation information that you have:

About your medical history

Please list any other ongoing medical problems:

Women Only:

What contraception are you using (if any):

Have you had a hysterectomy? *

Yes

No

Are you pregnant? *

Yes

No

When is your due date?

Sharing your health care records and information

The Summary Care Record and the sharing of basic information helps clinicians in A&E Departments and ‘Out of Hours’ health services to give you safe, timely and effective treatment. Your patient record will be held securely on confidentially on our electronic system, and will only be accessed by authorised healthcare professionals directly involved in your care. You will be asked if healthcare staff can look at your information every time they need to, unless it is an emergency and they are unable to; for instance if you are unconscious.

With your permission, this information will be shared electronically via:

SCR – NHS Summary Care Record (used nationally across England).
Gloucestershire Shared Health and Social Care Information (Joining up your information – JUYI) (Used locally across Gloucestershire)
Enhanced Data Sharing Model in SystmOne (EDSM) (Used nationally across all healthcare providers using SystmOne).

Your Summary Care Record contains basic information about:

Your current medications
Any allergies you have
Any bad reactions you have had to medicines

**SCR with Additional information can be added upon request to your GP practice. This includes:

Significant problems (past and present)
Significant procedures (past and present)
Anticipatory care information
End of life care information – as per EOLC dataset ISB 1580

JUYI contains information about:

Your current medications
Any allergies you have
Any bad reactions you have had to medicines
Your medical history and diagnoses
Test results and x-ray reports
Your vaccination history
General health readings such as blood pressure
Your appointments, hospital admissions, GP out-of-hours attendances and ambulance calls
Care / management plans
Correspondence such as referral letters and discharge summaries

Please note that these records are not connected with the Health and Social Care Information Centre care data project and will be used only for the purpose of enabling informed care to be supplied directly to you as an individual.

Parents, guardians or someone with power of attorney can ask for people in their care to be opted out, but ultimately it is the GP’s decision whether they share information, or not, because of their duty of care.

If you care caring for someone and feel that they are able to understand, then you should make the information about the different methods of sharing available to them.

Please tell us if you are happy for us to share this electronic information with clinicians in other NHS organisations (and Gloucestershire County Council social care in the case of JUYI) who are involved in your care.

Please read carefully and select one option for each question below:

Your Choice for the national SCR *

I would like my information shared through the Summary Care Record

I would like a Summary Care Record with additional information added**

I do not want my information shared through the Summary Care Record

Your Choice for Gloucestershire shared health and social care information (JUYI) *

I would like my information shared through the Gloucestershire shared health and social care information project

I do not want my information shared through the Gloucestershire shared health and social care information project

Enhanced Data Sharing Model (SystmOne) Sharing Out *

I would like my information shared out to SystmOne healthcare providers

I do not want my information shared out to SystmOne healthcare providers

Enhanced Data Sharing Model (SystmOne) Sharing In *

I want my GP practice to view data that is recorded at another SystmOne NHS organisation that may care for me.

I do not want my GP practice to view data that is recorded at another SystmOne NHS organisation that may care for me.

Signed: *

Date:

Full Name: *

Relationship:

If the person signing is not the patient, please give name and relationship to the patient.

Tell us whether you accept cookies

Patient Details

About you

Household Members

About your ethnic origin

About your lifestyle

Alcohol Consumption

This is one unit of alcohol:

And each one of these, is more than one unit:

About your medication history

Immunisation History

About your medical history

Women Only:

Sharing your health care records and information

Your Summary Care Record contains basic information about:

JUYI contains information about:

Coronavirus information from NHS111 online