Health Check for People with a Learning Disability

Please complete this form before you see the doctor. When you come to see the doctor please being all of your medicines with you.

Please select the practice location most relevant to this Online Form submission:

Title

Name

Last Name

Date Of BirthDD/MM/YYYY

Address

Postcode

Phone

Email

Are You

Male

Female

Best language for you to speak and understand being spoken to you

Religion

Do you have a health action plan?

Yes

No

Do you have a job?

Yes

No

What type of place do you live in?For example, a family home, a residential care home, your own home, supported living.

How do you communicate?

Talking

Signing

Using a communication aid

Pointing

Gestures

Select as many as you wish

Who is your main carer?

Telephone number for your main carer

Tell us the names of all the people who look after you:

Family

Paid carer

Healthcare worker

Social care worker

Do you care for anyone?

Yes

No

This could be children, parents or partner.

Do you have any other health conditions?

Yes

No

Do you have any allergies?

Yes

No

Do you have any fears or phobias?

Yes

No

What are the signs that you are in pain?

Do you drink alcohol?

Yes

No

Do you smoke?

Yes

No

Do you take any drugs such as cannabis, cocaine etc?

Yes

No

Do you take any tablets that are not from a healthcare worker (e.g. doctor or nurse) such as painkillers, vitamins etc

Yes

No

Do you have sex?

Yes

No

Do you have any problems sleeping?

Yes

No

Do you have any problems eating or drinking?

Yes

No

Do you have any problems swallowing?

Yes

No

Do you have constipation or diarrhoea?

Yes

No

Do you have any problems when you wee or poo?

Yes

No

Have your moods changed (e.g. are you more angry, or sad, or worried)?

Yes

No

Do you have sometimes get a pain in your chest?

Yes

No

Do you have any problems breathing?

Yes

No

Is there a family history of any medical illnesses, problems or learning disabilities?

Yes

No

Do you have any problems with any of the following:

Eyes / seeing things

Yes

No

Hearing

Yes

No

Your teeth and mouth

Yes

No

Feet

Yes

No

Hair, skin or nails

Yes

No

Do you see any of the following health professionals?

Opticians (eyes)

Yes

No

Audiologist (hearing)

Yes

No

Dentist (mouth and teeth)

Yes

No

Podiatrist / Chiropodist (feet)

Yes

No

Physiotherapist

Yes

No

Occupational therapist

Yes

No

Psychologist / Psychiatrist

Yes

No

Speech Therapist

Yes

No

Dietician

Yes

No

Other Health Questions

Do you exercise?

Yes

No

For men and women aged 60-69

Have you received a kit to test for bowel cancer?

Yes

No

For men (all ages)

Have you had any pain or swelling in your testicles?

Yes

No

For women (all ages)

Do you have periods?

Yes

No

Are there any problems with your periods?

Yes

No

Are your periods?

Painful

Very heavy

Irregular (for example you bleed between periods)

Select as many as needed

Do get any vaginal discharge that makes you feel sore or is smelly?

Yes

No

Have you had any pain or lumps in your breasts?

Yes

No

If you are over 50 years old, have you had a breast screening test?

Yes

No

If you are between 25 and 64 years old, have you had a cervical smear test?

Yes

No

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This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Longford Primary Care Centre - Dr Princewill & Partners • Longford Road, Longford, Coventry, West Midlands, CV6 6DR.

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