About YouAppointment Date*Please enter the date of your appointment dd/mm/yyyy Date Format: DD slash MM slash YYYY Please enter the time of your appointment*24 Hour Clock Format : HH MM Date of birth* Date Format: DD slash MM slash YYYY Confirmation Email*Please enter your e-mail address so that we can send you a confirmation e-mail to confirm we have received your updated medical history and Covid-19 risk assessment. Enter Email Confirm Email Are you completing this form yourself or on behalf of someone*I am completing the form myselfI am completing the form on behalf of someoneName of person completing form* First Last Email* Enter Email Confirm Email Your relationship to the patient*ParentGuardianPower of attorneyGrandparentCarerFriendConfirm any changesHave there been any changes to your medical status, medication, GP you are registered with, or general health since you last completed the full medical history form?*Yes - There have been changesNo - There HAVE NOT been any changesWhat has changed*Please select all that apply The medication I take has changed I have seen the GP (Doctor) for something since I last saw you I have seen a specialist about something since I last saw you There have been general changes to my health I have changed GP (Doctor) My smoking habits have changed My alcohol intake (amount) or type of alcohol I consume has changed Changes to your GP's detailsWe need your GP's details in order to liaise with them over your care, to check medication interactions and to generally provide you with safe effective care.New Doctors name*New Surgery address* Surgery name Building no. & road Town County Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Consent I agree to data being exchanged between us and my GP/doctors sugery - If you do not consent to this, then it may delay or compromise your treatment. If you wish to withdraw this consent at any time, all you need to do is drop us an e-mail or write to us as we will need to keep a written copy of your withdrawal on file.About the changes to your healthPlease tell us what medication you are taking. Including; Drug name, dose and how often you take it.*It's really important we know what you're taking to ensure any procedures we do, drugs that we use or things we may prescribe, don't cause any interactionsPlease tell us a little more abut why you saw your GP*Please tell us a little more about what/why you saw a specialist*Please tell us about the changes to your general health*Tell is a little more what has changed with regards to smoking*Tell us what has changed about the amount/types of alcohol you consume*Covid-19 InformationIt is really important that you respond to these questions fully and honestly for us to be able to risk-assess you for attendance at the practice, to reduce your risk, reduce the risk to our team, other patients and the wider community.Have you had Coronavirus?*Yes - I was tested and it was confirmedYes - I think I have but have not been testedNo - I have not had CoronavirusWould you like to upload proof of test or send it by e-mail?*I'll upload proof of testI'll send it by e-mail to email@example.comUpload proof of test*Please upload proof of Coronavirus test - Max 2MBHave you returned from abroad in the last 14 days?*This includes any trip away from the mainland of the UK including trips to Jersey, Guernsey etc..YesNoPlease tell us where you went, how you travelled and dates of travel*Have you in the last three weeks been in contact with anyone with or that may have Coronavirus?*Yes, I have definitely been in contact with someone with confirmed COVID-19 infection but I am asymptomatic (have no symptoms)Yes, I am likely to have been in contact but it is unconfirmed and I am asymptomatic (have no symptoms)I have been out and about and been in contact with people, none of whom to the best of my knowledge has Covid-19I have not been in contact with anyone, but have been out of the house occasionallyI have not been in contact with anyone, but have been out of the house many timesI have completely self isolated at home and have not been out of the houseSigns & Symptoms - Please tick all that apply* I do not currently have any symptoms Persistent cough Shortness of breath or difficulty breathing Temperature above 37.8 degrees Any symptoms of respiratory tract illness whatsoever Loss of taste and / or smell Unexplained tiredness or lethargy Muscular aches Do you live with other people?*No - I live on my ownYes - I live with my familyYes - I live with other peopleDo any of these people go out to work?*YesNoIn the last 4 weeks how would you subjectively assess your risk of being exposed to or infected by COVID-19*High risk - Frontline health care worker or confirmed case of infection at home or at workModerate risk - Key worker in contact with public but without symptoms or known exposure to an infected individualLow risk - Have been isolated / in lockdown alone or with family members with minimal social contact and no known exposure to an infected individualPreviously infected and recovered - Confirmed by hospital testing with documentationYour NHS risk category*Based on the information at: https://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk/whos-at-higher-risk-from-coronavirus/ Where would you place yourself as far as being 'at risk'High risk (clinically extremely vulnerable)Moderate risk (clinically vulnerable)Low riskMore information abour your NHS risk category*You have identified yourself as high or moderate risk. Please tell us a little more about what makes you a high or moderate risk according to the current information released by the NHS/Government.How do you plan to travel to your next appointment*In order to help us plan for your arrival, it's useful to know how you plan to arrive for your next appointment.CarTaxiBusWalkBicycleTrain & TaxiHelicopterFinallyCAPTCHAConsent* The information I have provided in this form is to the best of my knowledge correct and truthful, should changes occur I undestand that it is my responsibility to keep the practice updated of changes by completeing this form at any time. I consent to basic contact information being shared (if required) with any official government 'Track and Trace' system in connection with Coronavirus (Covid-19)NameThis field is for validation purposes and should be left unchanged.