Video Group Clinic Registration and Agreement

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Please be reassured that the registration information and results of this questionnaire will be sent to the practice but remain confidential.

Personal Details

Please double check you've entered the correct email address

Please note that you will need to remember this as it will be used to verify your identity at the start of the clinic

Family member, carer, or friend details

Please note that they will need to remember this as it will be used to verify their identity at the start of the clinic

Questionnaire

Before you attend your clinic, the clinician needs the following information from you. The clinician and facilitator of the group clinic will be able to access your answers in order to provide you with care.

Please be reassured that the information you submit will be sent to the practice and remain confidential.

Do you currently smoke?: *

Is there any family history (parents or siblings) of breast cancer?: *

Is there any family history or personal history of clots/thrombosis?: *

Would you like to complete a Symptom Questionnaire which may help us help you?: *

Let’s explore your symptoms

This is a validated questionnaire. It will help you understand your symptoms.

Please indicate the extent to which you are bothered at the moment by any of these symptoms by placing a tick in the appropriate box and add up your score

Heart beating quickly or strongly: *

Feeling tense or nervous: *

Difficulty sleeping: *

Excitable: *

Attacks of panic: *

Difficulty concentrating: *

Feeling tired or lacking energy: *

Loss of interest in most things: *

Feeling unhappy or depressed: *

Crying spells: *

Irritability: *

Feeling dizzy or faint: *

Pressure or tightness in head or body: *

Part of the body feeling numb or tingling: *

Headaches: *

Muscle and joint pains: *

Loss of feeling in hands or feet: *

Breathing difficulties: *

Hot flushes: *

Sweating at night: *

Loss of interest in sex: *

My total score:

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Agreement

By participating in this group clinic I agree that

National Cyber Security Centre information on changing the privacy settings on your device to preserve your personal information:

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If, after reading this agreement, you no longer wish to attend the menopause group clinic, please contact us so that we can reallocate your place to help another person keep well and improve their health.

Signature

To confirm that you understand the Group Clinic Agreement and wish to attend the menopause group clinic, please provide your signature.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Whitstable Medical Practice

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Video Group Clinic Registration and Agreement

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