Student medical questionnaire

Personal Information

Full Name:

University Accommodation Address:

Preferred Contact Number:

Medical Details

Do you suffer from: (Tick all that apply)

Diabetes

Asthma

Epilepsy

Are you suffering from any other significant illnesses requiring treatment or medication?

What medication do you take? (Please give the exact name, strength and dose. If you have a computer printout of your repeat medication, please provide this)

Are you allergic to any medication?

Yes

No

Please give the name of the medication:

How many units of alcohol do you drink per week? (1 unit = half a pint of lager or 1 measure of spirit)

Do you smoke?

Yes

No

We advise all smokers to stop.

Vaccinations

Have you had Measles Mumps and Rubella immunisations?

Yes

No

Date if known

Have you had MEN ACWY vaccination?

Yes

No

Date if known

Next of Kin details

Name:

Relationship:

Contact number:

Address:

To provide a confidential service, it may be necessary for The Alney Practice to obtain your up to date contact details in order that test results and other sensitive medical information can be processed effectively. According to the Data Protection Act 1998, we need your permission to obtain this information, please indicate if you are happy for this to happen.

Yes

No

JUYI – joining up Your Information – Gloucestershire shared health and social care information (used locally across Gloucestershire). Please indicate if you would like your information to be shared through JUYI.

Yes

No

Summary Care Record (SCR)

The new NHS Summary Care Record has been introduced to help deliver better and safer care and give you more choice about who you share your healthcare information with.

What is the new Summary Care Record?

The summary care record contains basic information about

Any allergies you may have
Unexpected reactions to medications
Any prescriptions that you have recently received

The intention is to help clinicians in A&E Departments and Out of Hours health services to give you safe, timely and effective treatment. Clinicians will only be allowed to access your record if they are authorised to do so and then only if we have your permission.
You do not have to have a Summary Care Record, although you are strongly recommended to consider this choice. If you are happy for a Summary Care Record to be set up for you then you need to take no further action.

I do not want a Summary Care Record

Signature:

Date: