Holiday Extras Questionnaire

We look forward to welcoming you to Woodchurch Surgery, where we will host you to identify and discuss health concerns. A traditional screening medical examination will take place along with targeted discussions and examinations that will be relevant to your concerns, your history and your family history, which define your own health risks. Where necessary we will agree goals to set to try and maintain or improve your mental and physical health.

To help us and for you to benefit the most please take a moment to complete this prior to you setting off to come and see us. It may be worth talking to your family to complete any details. Your records will be retained securely and in full confidence in line with Data Protection Act 2018.


Your Details

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Your Activity

Please enter number of units
Please provide any relevant details
Please provide any relevant details
Please provide any relevant details
Happiness/Contentment Scale
Please let us know in general how happy/contented you feel

Current Health Concerns

Please provide as much detail as possible
Please provide as much detail as possible

Medication

Please provide as much detail as possible, including dosages
Please provide as much detail as possible, including dosages

Medical History

Current or former medical issues
If any of the above were selected, please provide details here