Student Medical Questionnaire

Student Medical Questionnaire

Personal Information

Please use the format: DD/MM/YYYY
Please use the format: example@mail.com

Medical Details

Do you suffer from: (Tick all that apply)
Are you allergic to any medication?
Do you smoke?

We advise all smokers to stop.

Vaccinations

Have you had Measles Mumps and Rubella immunisations?
Have you had MEN ACWY vaccination?

Next of Kin details

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.
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.

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.