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Initial Assessment
Update client details
Client details
Communication needs
Medical details
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Client details
First name
Last name
Preferred name
Only complete if different from first name
Date of birth
Expected format: dd/mm/yyyy
Gender
Select...
Female
Male
Other
Prefer not to say
Ethnic group
Select...
Prefer not to say
Unknown
English, Welsh, Scottish, Northern Irish or British
Irish
Gypsy or Irish Traveller
Any other White background
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed or Multiple ethnic background
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
African
Caribbean
Any other Black, African or Caribbean background
Arab
Any other ethnic group
Phone
Alternative phone
Email
Address line 1
Address line 2
Address line 3
Town or city
Postcode
Communication needs
Does the participant need an interpreter?
Yes
No
Interpreter details
Does the participant have communication difficulties?
Yes
No
Communication difficulties details
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Who should contact be made with?
Client
Other
Contact's first name
Contact's last name
Contact's phone
Contact's email
Contact's relationship
Best contact time
e.g. Mon-Wed 9am-1pm
Medical details
NHS Number
GP Practice
Select...
19 Beaumont Street
27 Beaumont Street
28 Beaumont Street
Abingdon Surgery
Alchester Medical Group/Langford Medical practice
Alchester Medical Group/Victoria House Surgery
aliquid
amet
asperiores
Bampton Surgery
Banbury Cross Health Centre (includes West Bar surgery)
Banbury Road Medical Centre
Bartlemas Surgery
Barton Surgery / Hedena Health
beatae
Berinsfield Health Centre
Bicester Health Centre
Bloxham Surgery (Hook Norton)
(Botley) & Kennington Medical Centre
Botley (& Kennington) Medical Centre
Broadshires Health Centre
Burford Surgery
Bury Knowle Health Centre
Chalgrove and Watlington Surgeries
Chipping Norton Health Centre (Merger of West Street & White House Surgeries.)
Church Street Practice
Clifton Hampden Surgery
Cogges Surgery
consequatur
Cowley Road Medical Practice (formerly known as East Oxford Health Centre)
Cropredy Surgery
culpa
cum
cum
cum
cupiditate
Cuttleslowe Surgery
debitis
Deddington Health Centre
Didcot Health Centre
distinctio
dolores
dolorum
Donnington Medical Partnership (formerly known as Donnington HC)
ea
eaque
earum
error
et
exercitationem
explicabo
fuga
fugiat
Goring & Woodcote Medical Practice
Gosford Hill Medical Centre
hic
Hightown Surgery
Hollow Way Medical Centre
Horsefair Surgery
id
ipsa
ipsam
ipsam
Islip Surgery
Jericho Health Centre (Leaver)
Jericho Health Centre (Observatory)
King Edward Street Medical Practice
laboriosam
laborum
Long Furlong Surgery
Luther Street Medical Centre
Malthouse Surgery
Marcham Road Surgery
Mill Stream Surgery, Benson
modi
molestiae
mollitia
Montgomery House Surgery
Morland House Surgery, Wheatley
natus
Nettlebed Surgery, near Henley on Thames
Newbury Street Practice (incl. Newbury St Pract.)
Oak Tree Health Centre
odio
odit
odit
officia
officiis
optio
porro
possimus
quae
quae
quaerat
quaerat
quam
qui
quo
rem
repudiandae
repudiandae
Sibford Surgery
sit
soluta
soluta
Sonning Common Health Centre
South Oxford Health Centre (a subsidiary of St Bartholomews MC)
St Bartholomew’s Medical Centre
St Clement’s Surgery
Summertown Health Centre
Temple Cowley Health Centre
tempore
tenetur
tenetur
The Bell Surgery, Henley on Thames
The Charlbury Surgery
The Eynsham Medical Group
The Hart Surgery, Henley on Thames
The Key Medical Practice (includes Yarnton Surgery)
The Leys Health Centre
The Manor Surgery
The Nuffield Health Centre
The Rycote Practice, Thame
The Wychwood Surgery
ullam
unde
velit
velit
voluptate
voluptatum
Wallingford Medical Centre
White Horse Surgery
Windrush Health Centre
Windrush Surgery
Wolvercote Surgery
Wood Farm Health Centre
Woodlands Surgery
Woodstock Surgery
GP Practice (if not found above)
*
Details of health conditions and issues (tick all that apply)
Asthma
High cholesterol
Atrial fibrillation
Joint replacement (please state)
Back pain
Musculoskeletal condition
Cancer
Neurological disorder (e.g. Parkinson's, Multiple Sclerosis/MS)
Coronary heart disease / Angina
Obesity (BMI 30+)
Dementia
Osteoarthritis (please state area/s affected)
Diabetes Type 1
Osteopenia/Osteoporosis
Diabetes Type 2
Respiratory Disease (e.g. COPD or emphysema)
Falls
Rheumatoid arthritis
Heart failure
Stroke and/or TIA
High blood pressure
Other
Please state:
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Mental health conditions
Anxiety
Psychosis
Bipolar disorder
PTSD
Depression
Schizophrenia
OCD
Stress
Personality disorders
Other (please state)
Please state:
Mollitia placeat dolorum cupiditate odit.
Details of disabilities that limit day-to-day activities
Difficulty with memory or concentration
Social or behavioural issues (e.g. due to neuro diverse conditions such as Autism, Attention Deficit Disorder or Asperger's Syndrome)
Hearing (e.g. due to deafness or partial hearing)
Stamina or breathing difficulty
Learning disability
Vision (e.g. due to blindness or partial sight)
Mental health
Other impairment
Mobility, such as difficulty walking short distances, climbing stairs, lifting, and carrying objects.
Prefer not to say
Does the client look after, care for or give any help or support to family members, friends, neighbours or others because of either long-term physical or mental ill-health / disability, or problems related to old age?
General notes about any of the above or any other relevant medical info
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