Patient Health Information Request

Fields marked with a red * are mandatory.

We are recording all of our patient’s Ethnicity, BMI and Smoking status. This has become very important because these are risk factors for COVID19 and how unwell you may become if you contract the virus. We know that these are also risk factors for other illnesses such as diabetes. Having this information on your medical notes means that we can calculate your risk  and then we can initiate further monitoring and support services if you have been confirmed positive for COVID 19. It will also help us deliver high quality care to people who need it most.

Stay safe.

PLEASE COMPLETE A SEPORATE FORM FOR EACH HOUSEHOLD MEMBER REGISTERED WITH US (AMC)

Health Questionnaire
First
Last
Smoking status