My details and any existing conditions

What should your healthcare professional know?

Your Name *

Email Address *

Name of heath practice *

GP's name *

GP practice phone number

GP practice address

Important things I would like my doctor, nurse or pharmacist to know that about me (please tick as appropriate):

My hearing is not so good

I sometimes struggle to speak or communicate

I have trouble with my vision (glasses or contacts)

I live alone and do not have anyone who can help me (for example, go to the shops, or help me about the house)

I have trouble getting about (mobility issues)

I am a carer for another person

Anything else (for example, my religion, dietary requirements, allergies, risk of falls or tumbles)

Condition

Additional Notes