Regal Chambers Surgery

50 Bancroft, Hitchin, Herts SG5 1LL

Telephone: 01462 453232

E82075.regalchamberssurgery@nhs.net

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Health Assessments
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PHQ-9 Depression Questionnaire

PHQ-9 Depression Questionnaire

Full Name(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Email(Required)

Phone Number(Required)

Mental 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(Required)

Not at all

Several days

More than half the days

Nearly every day

Feeling down, depressed, or hopeless(Required)

Not at all

Several days

More than half the days

Nearly every day

Trouble falling or staying asleep, or sleeping too much(Required)

Not at all

Several days

More than half the days

Nearly every day

Feeling tired or having little energy(Required)

Not at all

Several days

More than half the days

Nearly every day

Poor appetite or overeating(Required)

Not at all

Several days

More than half the days

Nearly every day

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

Not at all

Several days

More than half the days

Nearly every day

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

Not at all

Several days

More than half the days

Nearly every day

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(Required)

Not at all

Several days

More than half the days

Nearly every day

Thoughts that you would be better off dead or of hurting yourself in some way(Required)

Not at all

Several days

More than half the days

Nearly every day

Score(Required)

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?(Required)

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Comments

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

73615

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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Update your details

"*" indicates required fields

Name*

First Last

Date of Birth*

Address*

Phone*

Email*

Smoking Status*

How many per day?*

Name

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

35093

Friends & Family Test

"*" indicates required fields

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?

Phone

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

17074

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.

28282

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

Comments

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

55749

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