Regal Chambers Surgery

50 Bancroft, Hitchin, Herts SG5 1LL

Telephone: 01462 453232

E82075.regalchamberssurgery@nhs.net

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Epilepsy Review

Epilepsy Review

Full Name(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Email(Required)

Phone Number(Required)

How long has it been since your last epileptic fit?(Required)

Within the last week

1 to 4 weeks

1 to 6 months

6 to 12 months

Over 12 months

Are you currently on treatment for epilepsy?(Required)

Yes

No

How often do you have an epileptic fit?(Required)

None

Many seizures a day

Daily seizures

1 to 7 seizures a week

2 to 4 seizures a month

1 to 12 seizures a year

Comments

This field is for validation purposes and should be left unchanged.

96979

Opening Times

Monday
08:00am to 06:30pm
Phone lines closed 13.00-14.30
Tuesday
08:00am to 12:30pm
02:00pm to 06:30pm
Wednesday
08:00am to 06:30pm
Phone lines closed 13.00-14.30
Thursday
08:00am to 06:30pm
Phone lines closed 13.00-14.30
Friday
08:00am to 06:30pm
Phone lines closed 13.00-14.30
Saturday
CLOSED
Sunday
CLOSED

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"*" indicates required fields

Name*

First Last

Date of Birth*

Address*

Phone*

Email*

Smoking Status*

How many per day?*

Comments

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74748

Friends & Family Test

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We would like you to think about your recent experiences of our service.

Thinking about your recent visit, overall, how was your experience of our service?*

Very good

Good

Neither good nor poor

Poor

Very poor

Don't know

Please can you tell us why you gave your answer?

Email

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77600

Travel Risk Assessment

Please submit your travel risk assessment 6 weeks before your departure date.

This will allow our practice nurses to check your travel risk assessment and contact you with the necessary vaccines you may need and book you in for your vaccine appointment. If the form is submitted less than 6 weeks from your departure date we may not be able to offer an appointment. Please see link below for further information by searching relevant country and checking other vaccines that may be advised, depending on your individual circumstances and activities during your trip. These may not be available on the NHS and will need to be sourced through private travel clinic.
https://travelhealthpro.org.uk/countries

Update your details

"*" indicates required fields

Name*

First Last

Date of Birth*

Address*

Phone*

Email*

Smoking Status*

How many per day?*

Comments

This field is for validation purposes and should be left unchanged.

6427

Travel Risk Assessment

Full Name(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Gender(Required)

Male

Female

Email(Required)

Phone Number(Required)

Please supply information about your trip in the sections below

Date of Departure(Required)

DD slash MM slash YYYY

Total Length of Trip(Required)

Country to be visited(Required)

Exact Location or Region(Required)

City or Rural(Required)

Length of Stay(Required)

Have you taken out travel insurance for this trip?(Required)

Yes

No

Do you plan to travel abroad again in the future?(Required)

Yes

No

Type of travel and purpose of trip(Required)

Holiday

Business Trip

Expatriate

Volunteer Worker

Healthcare Worker

Staying in Hotel

Cruise Ship Trip

Safari

Pilgrimage

Medical Tourism

Backpacking

Camping / Hostels

Adventure

Diving

Visiting Friends / Family

Accommodation(Required)

Hotel

Camping

Hostels

Friends / Family

Please supply details of your personal medical history

Are you fit and well today?(Required)

Yes

No

Why?(Required)

Any allergies including food, latex, medication?(Required)

Yes

No

Details

Severe reaction to a vaccine before?(Required)

Yes

No

Details

Tendency to faint with injections?(Required)

Yes

No

Details

Any surgical operations in the past, including e.g. your spleen or thymus gland removed?(Required)

Yes

No

Details

Recent chemotherapy / radiotherapy / organ transplant?(Required)

Yes

No

Details

Anaemia?(Required)

Yes

No

Details

Bleeding / clotting disorders (including history of DVT)?(Required)

Yes

No

Details

Heart disease (e.g. angina, high blood pressure)?(Required)

Yes

No

Details

Diabetes?(Required)

Yes

No

Details

Disability?(Required)

Yes

No

Details

Epilepsy / seizures?(Required)

Yes

No

Details

Gastrointestinal (stomach) complaints?(Required)

Yes

No

Details

Liver and or kidney problems?(Required)

Yes

No

Details

HIV / AIDS?(Required)

Yes

No

Details

Immune system condition?(Required)

Yes

No

Details

Mental health issues (including anxiety, depression)?(Required)

Yes

No

Details

Neurological (nervous system) illness?(Required)

Yes

No

Details

Rheumatology (joint) conditions?(Required)

Yes

No

Details

Spleen problems?(Required)

Yes

No

Details

Any other conditions?(Required)

Yes

No

Details

Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)? Please list:

Women only

Are you pregnant?(Required)

Yes

No

Details

Are you breast feeding?(Required)

Yes

No

Details

Are you planning pregnancy while away?(Required)

Yes

No

Details

Please supply information on any vaccines or malaria tablets taken in the past

Tetanus/polio/diptheria

Typhoid

Cholera

Rabies

Yellow Fever

MMR

Hepatitis A

Hepatitis B

Japanese Encephalitis

BCG

Influenza

Pneumococcal

Meningitis

Tick Borne Encephalitis

Malaria Tablets

Other

ANY ADDITIONAL INFORMATION

Phone

This field is for validation purposes and should be left unchanged.

56287

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