Please enable JavaScript in your browser to complete this form.Enter Your Name *FirstLastDate of Birth *Address *What is the main reason for your appointment? *How long have you had this problem or these symptoms? *Less than 24 hours1–7 days1–4 weeks1–6 monthsMore than 6 monthsNot applicableDo you have any existing medical conditions? i.e. Hypertension, Diabetes, Asthma etc. *YesNoIf yes, please list your medical conditions. Are you currently taking any medicines, i.e. Prescribed, Homeopathic or Over the Counter? *YesNoPlease list your medications & doses, if known.Do you have any allergies or previous reactions to medicines? i.e. insects, food etc. *YesNoPlease provide details etc. know your Are you currently experiencing any of the following? *Chest painPalpitations or irregular heartbeatShortness of breathFainting or loss of consciousnessSevere or persistent vomitingNew severe headacheNew weakness or numbnessDifficulty speakingNew vision changesRecent fallRecent head injuryNone of the aboveIf you are experiencing any of the above, please call 999 urgently.Do you smoke or use tobacco/nicotine products i.e. Cigarettes, E – Cigarettes, Vapes etc. *YesNoPreviouslyDo you currently use any recreational or non-prescribed drugs? *Do you drink alcohol? *YesNoIf yes, how many units per week?Is there anything else you would like your GP to know before your appointment?Name of your NHS GP Practice *Are you happy for relevant information from your consultation to be shared with your NHS GP where appropriate for your ongoing care? *YesNoWhere relevant, are you currently pregnant, possibly pregnant or breastfeeding?PregnantPossibly pregnantBreastfeedingNoPrefer not to sayNot applicableConfirmation *I confirm that I am 18+ and the information provided is accurate to the best of my knowledge.Acknowledgement *I understand that this booking form does not replace urgent or emergency medical assessment.Submit
