Online Forms - Castleford Medical Practice

Asthma Review

This form is used for your annual asthma review. Please answer the questions and submit this form to us. If your symptoms are deteriorating or you have any concerns, please make an appointment to the respiratory nurse or a Doctor as well.

Asthma Review Form

YOUR DETAILS

Name

First Last

Date of Birth

DD slash MM slash YYYY

Contact Number

ASTHMA REVIEW

In the last month have you had difficulty sleeping due to your asthma (including cough)?

Yes Optional

No Optional

Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day?

Yes Optional

No Optional

Has your asthma interfered with your usual daily activities (e.g., school, work, housework)?

Yes Optional

No Optional

How often do you need to use your reliever inhaler?

Never Optional

1-2 times a month Optional

1-2 times a week Optional

1-2 times a day Optional

2+ times a day Optional

Since your last review, have you needed to see a doctor as an emergency or attend the A&E department of a hospital as a result of your asthma?

Yes Optional

No Optional

Since your last review, have you needed a course of steroid tablets to get your asthma under control?

Yes Optional

No Optional

Do you smoke?

Yes Optional

No Optional

Did you have a flu vaccination last flu season?

Yes Optional

No Optional

Please list the inhalers you use daily or on a regular basis (name/strength/how many puffs/how many times a day/via a space device?) Optional

ASTHMA CONTROL SCORE

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?

All of the time – 1 Optional

Most of the time – 2 Optional

Some of the time – 3 Optional

A little of the time – 4 Optional

None of the time – 5 Optional

During the past 4 weeks, how often have you had shortness of breath

More than one a day

Once a day – 2

3-6 times a week – 3

1-2 times a week – 4

Not at all – 5

During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning?

4 or more times a week – 1

2-3 nights a week – 2

Once a week – 3

Once or twice – 4

Not at all – 5

During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? *

3or more times a week – 1

1-2 times a day – 2

2-3 times a week – 3

Once a week or less – 4

Not at all – 5

How would you rate your asthma control during the past 4 weeks?

Not controlled – 1

Poorly controlled – 2

Somewhat controlled – 3

Well controlled – 4

Completely controlled – 5

Consent

I consent to the practice collecting and storing my data from this form.

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Breathlessness Review

If you have been advised by the surgery to submit a breathlessness review on a regular basis please use this form.

Breathlessness Review Form

YOUR DETAILS

Name

First Last

Date of Birth

DD slash MM slash YYYY

Contact Number

BREATHLESSNESS REVIEW

HOW DO YOU RATE YOUR LEVEL OF BREATHLESSNESS?

Consent

I consent to the practice collecting and storing my data from this form.

Contraceptive Pill Review

If you have been advised by the surgery to submit a contraceptive pill review please use this form.

Contraceptive Pill Review Form

YOUR DETAILS

Name

First Last

Date of Birth

DD slash MM slash YYYY

Contact Number

CONTRACEPTIVE PILL REVIEW

Consent

I consent to the practice collecting and storing my data from this form.

Will you be 35 years or older within the next 12 months?

Yes

Weight Optional

Smoking Status

Smoker Optional

Ex-Smoker Optional

Non-Smoker Optional

Have you, or any of your immediate family (mum, dad, brothers or sisters) been diagnosed with any of the following conditions within the past 12 months? Optional

Have you been diagnosed with or experienced any of the following conditions in the past 12 months? Optional

Are you currently taking any of the following medications?

Anti-epileptic medication St Johns Wort Optional

Rifampacin Optional

St Johns Wort Optional

Since your last review, have you needed to see a doctor as an emergency or attend the A&E department of a hospital as a result of your asthma?

Yes Optional

No Optional

Do you suffer from migraines with aura, or a headache associated with weakness or numbness on one side of your face or body, or difficulty with speech?

Yes

Have you forgotten to take your pill on more than one occasion per month?

Yes Optional

No Optional

Have you suffered from any irregular vaginal bleeding, bleeding between periods or bleeding after sex in the past 12 months?

Yes Optional

No Optional

Would you like to discuss 'what to do in the event of a missed pill' with you GP or practice nurse?

Yes Optional

No Optional

Would you like to discuss long acting reversible contraception options with you GP or practice nurse?

Yes Optional

No Optional

Consent

I consent to the practice collecting and storing my data from this form.

Epilepsy Review

If you have been advised by the surgery to submit an epilepsy review please use this form.

Epilepsy Review Form

YOUR DETAILS

Name

First Last

Date of Birth

DD slash MM slash YYYY

Contact Number

EPILEPSY REVIEW

How long has it been since your last epileptic fit?

Within the last week Optional

1 to 4 weeks Optional

1 to 6 months Optional

6 to 12 months Optional

Over 12 months Optional

Are you currently on treatment for epilepsy?

Yes Optional

No Optional

Has your asthma interfered with your usual daily activities (e.g., school, work, housework)?

Yes Optional

No Optional

How often do you have an epileptic fit?

None

Daily seizures

Many seizures a day

1 to 7 seizures a week

2 to 4 seizures a month

1 to 12 seizures a year

Are you a woman aged between 18 and 55?

Yes

If yes, would you like some information regarding contraception, conception and pregnancy and how this is affected by your epilepsy medication?

Yes

Consent

I consent to the practice collecting and storing my data from this form.

Hypothyroid Self Assessment

If you have been advised by the surgery to submit hypothyroid self assessment please use this form.

Hypothyroid Self Assessment

YOUR DETAILS

Name

First Last

Date of Birth

DD slash MM slash YYYY

Contact Number

HYPOTHYROID SELF ASSESSMENT

Weight

Pulse (If it is less than 60 or above 80 when resting please discuss this with your doctor)

Change in Weight: Optional

Have you had your blood tested for thyroid in the last 9 months?

Yes Optional

No Optional

I can’t remember Optional

Consent

I consent to the practice collecting and storing my data from this form.

Male Urinary Tract (IPSS) Assessment

If you have been advised by the surgery to submit Male Urinary Tract (IPSS) review please use this form.

Male Urinary Tract (IPSS) Assessment Form

YOUR DETAILS

Name

First Last

Date of Birth

DD slash MM slash YYYY

Contact Number

URINARY TRACT REVIEW

How often does your bladder not feel empty when finished passing urine?

How often do you need to pass urine within 2 hours of last urinating?

How often does the flow stop and start when passing urine?

How often is it hard to delay passing urine?

How often is the flow poor?

How often do you need to push or strain to begin?

How often do you need to pass urine after going to bed?

More than 4 Optional

4 Optional

3 Optional

2 Optional

1 Optional

None Optional

Consent

I consent to the practice collecting and storing my data from this form.

Patient Health Assessment

If you have been advised by the surgery to submit a Patient Health Questionnaire (PHQ-9) please use this form.

Patient Health Assessment (PHQ-9)

YOUR DETAILS

Name

First Last

Date of Birth

DD slash MM slash YYYY

Contact Number

PATIENT HEALTH REVIEW

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things Optional

Feeling down, depressed, or hopeless

Trouble falling or staying asleep, or sleeping too much

Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about yourself — or that you are a failure or have let yourself or your family down

Trouble concentrating on things, such as reading the newspaper or watching television

Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual

Thoughts that you would be better off dead or of hurting yourself in some way *

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Social situations due to a fear of being embarrassed or making a fool of myself

Certain situations because of a fear of having a panic attack or other distressing symptoms (such as loss of bladder control, vomiting or dizziness)

Certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confined spaces, driving or flying)

Consent

I consent to the practice collecting and storing my data from this form.

Smoking Review

If you have been advised by the surgery to submit smoking review please use this form.

Smoking Review Form V2

YOUR DETAILS

Name

First Last

Date of Birth

DD slash MM slash YYYY

Contact Number

SMOKING REVIEW

Do you currently smoke?

Yes Optional

No Optional

If 'Yes' How many cigarettes do you smoke in a day?

1 to 9 Optional

10 to 19 Optional

20 to 39 Optional

40 or more Optional

If 'No' Have you smoked in the past?

Yes Optional

No Optional

IF 'YES' HOW MANY CIGARETTES DID YOU SMOKE IN A DAY?

1 to 9 Optional

10 to 19 Optional

20 to 39 Optional

40 or more Optional

Consent

I consent to the practice collecting and storing my data from this form.