MEDICAL SCREENING
Name:
Date of Birth:
Telephone Number:
Email:
Please fill this in either adding free text or deleting statements that do not apply
to you
Please return to Jonathan.Lubin@gp-E83037.nhs.uk
Medical Issues and Symptoms:
Past Medical History:
Family Medical History
Current Medication:
Smoking:
Current smoker
Have you ever smoked?
How many years
smoking
Number daily on average
Alcohol Intake
Units per day (average glass of wine 1U,
½ pint 4% beer 1U, single spirit 1U)
Exercise:
Frequency of exercise
Type of exercise
Diet:
Allergies:
Include drug allergy e.g. penicillin and non drug allergy e.g. animals
Other Lifestyle factors:
Sleep:
Hours per night
Quality (do you wake feeling
refreshed?)
Broken sleep, if so why?
SYMPTOMS:
Weight:
Appetite:
GASTROINTESTINAL SYMPTOMS:
Symptom:
Yes/no
Difficulty swallowing/food getting
stuck
Burning behind sternum/acid in
mouth/feeling a lump in throat
Dyspepsia or upper abdominal
pain after food
Bloating or abdominal distension
Bowel Frequency
Stool consistency
Blood in stool
Mucous in stool
CARDIOVASCULAR SYSTEM
Symptoms:
Yes/No
Chest Pain on Exertion
Shortness of Breath on exertion
greater than expected
Shortness of breath in bed at
night
Needing many pillows to stop
shortness of breath at night in
bed
Palpitations: Sensation of rapid
heart beat
Irregular heart beat
Extra or missed beats
Swelling of Ankles
Pain in calves on exertion or
walking up hills
Do you have any difficulty with
maintaining an erection?
Details
Details
RESPIRATORY:
Symptoms
Cough: Dry
Cough: With sputum
(include colour)
Cough: with blood
Wheeze (include time,
activities and other
causes)
Difficulty breathing
Shortness of breath
Pain breathing
Yes/No
KIDNEY AND BLADDER
Symptoms
Yes/No
Frequency of passing
urine: Daytime
Frequency of passing
urine: Night
Good or poor urine
stream?
Do you have to wait to
pass urine?
Does the urine dribble at
the end?
Is there blood in the
urine?
NERVOUS SYSTEM
Symptoms
Faints
Fits
Headaches
Vertigo
Loss or reduction in skin
sensation
Pins and needle, if so
where and when
Yes/No
Details
Details
Details
MUSCULOSKELETAL SYSTEM
Symptoms
Yes/No
Back Pain
Radiation of back pain to
leg
Joint Pain
Joint Stiffness
Joint Swelling
EYES
Symptoms
Floaters
Flashing Lights
Eye Pain
Eye Irritation
EARS/HEARING
Symptoms
Vertigo
Tinnitus
Loss of Hearing
SKIN
Symptom/condition
Rashes
Moles
Other
Yes/No
Yes/No
Details
Yes/No
Details psoriasis
Details
Details
Medical Examination:
Height
Weight
BMI
Anaemia
Cyanosis
Clubbing
Jaundice
Lymph Glands: Cervical
Lymph Glands: Axillary
Lymph Glands: Inguinal
CVS:
Heart Rate
Blood pressure
JVP
Ankle/leg swelling (oedema)
Peripheral pulses
Carotid Bruit
Femoral Bruit
Heart Sounds
Varicose Veins
ECG
RESPIRATORY:
Trachea
Expansion
Percussion note
Peak flow
Breathe sounds
ABDOMEN
Soft/hard/firm
Masses
Tender/Pain
Liver
Kidneys
Spleen
Hernias
Testis
Bowels sounds
Rectal examination
NERVOUS SYSTEM:
Cranial nerves
Optic fundi
Coordination: Tremor
Coordination: Finger to
nose
Coordination:
Dysdiadokinesis
Coordination: Rhomberg
Coordination: Nystagmus
Power: upper limbs
Power: Lower limbs
Sensation: Light touch
Sensation: Pin prick
Sensation: Joint position
Sensation: Vibration
REFLEXES
Biceps
Triceps
Supinator
Knee
Ankle
Plantar
LEFT
Joints:
Cervical spine
Thoracolumbar spine
Shoulders
Hips
Knees
Functional Assessment
Standing on toes
Hopping on each foot
Kneeling and rising without use of
hands
Skin:
Normal
Ears:
Examination
Audiometry
Hospital anxiety
and depression
test
Anxiety /21
Depression /21
RIGHT
PATHOLOGY TESTING
Urine
Glucose
Protein
Blood
Nitrite
(urine
infection
test)
Result
White cells
Blood tests
Haemoglobin
g/dl
Normal Range
13-18g/dl
ESR
mm/hr
<10mm/hr
Creatinine
umol/l
75-125 umol/l
Glucose
mmol/l
<6.1mmol/l
TSH
mU/l
0.4-4 mU/l
Free T4
Pmol/l
Prostate
Specific Antigen
Free PSA
Total
mmol/l
Cholesterol
HDL
mmol/l
10-24.5 pmol/l
<4ug/L
LDL
mmol/l
1-5 mmol/l
Triglycerides
Faecal Occult
Blood
mmol/l
0.3-2.2 mmol/l
<5.7mmol/l
0.9-1.8 mmol/l
Ketones
SUMMARY AND ACTION PLAN