University Student Questionnaire

By providing your email and mobile you consent to the practice contacting you by these methods of communication for direct patient care- including screening programmes. please bear this in mind if you share an email account.

Last Updated: 30/04/2021

Your Contact Details

Title

First Name *

Last name (Surname) *

Date of Birth enter in format **/**/**** *

Mobile Number *

Email Address - please check this is entered correctly, this will be the main way we contact you. We will send your online services log-in to this account so please check your junk folder if you don't receive those emails within 7 days. *

Information About You

Transgender Patients

We may need to ask you for further information to be able to locate your medical records.

Male to female?

Yes No

Female to male?

Yes No

Medical Information

That requires current treatment and/or regular medication. If you take regular medication please email a copy of your most recent repeat prescription counterfoil or book a telephone appointment with our clinical pharmacist to set up these medications so you can continue taking them.

Vaccinations

If you are over 18, and this is your first ever year at a university, you will be eligible for this vaccine. Many of you will have received this before leaving home to come to university but if not, we will be in contact with you. Overseas student? We will need you to supply us with a list of the vaccinations you have received.

Have you had the Men ACWY vaccine, to protect you from Meningococcal groups A,C,W and Y? *

Yes No

If yes please give the date

Females Only

Do you have a contraceptive coil fitted?

Yes No

Are you pregnant?

Yes No

Have you ever been diagnosed with Gestational Diabetes during a pregnancy?

Yes No

If Yes, please state your estimated due date

If 'yes', what date did you have the coil fitted?

Do you have a contraceptive implant fitted?

Yes No

If 'yes' what date did you have the contraceptive implant fitted?

Smoking

If you would like help and advice please phone Healthy Cornwall 01209 615600 to book an appointment with a stop smoking counsellor.

Do you smoke? *

Yes No

If 'No', have you ever smoked? *

Yes No

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?

Alcohol

How many units of alcohol do you drink per week? As a guide a single shot of spirits is 1 unit, a pint of lower-strength lager/beer/cider (ABV 3.6%) is 2 units and a standard glass of red/white/rosé wine is 2.1 units *

0 - Don't drink alcohol

1-14

15-21

22-28

36-42

43-49

50 or more

MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion? *

How often during the last year have you not been able to remember what happened when drinking the night before? *

How often during the last year have you failed to do what was expected of you because of drinking? *

Has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? *

Consent

if you would like to allow the Practice to discuss medical matters with your parent(s), next of kin, guardian or nominated person please complete their details below: This consent will remain on your notes until you advise the surgery otherwise.

Full Name

Relationship to you

Daytime Contact Telephone Number

Summary Care Records

A Summary Care record is an electronic record that can help give you safer, faster care by giving healthcare staff instant access to information about your MEDICINES, ALLERGIES and MEDICINES which make you ill.

I would like to share my summary care record *

Yes No

Enhanced Data Sharing

SystmOne is the clinical computer system used by Penryn Surgery. Opting into this method of sharing your medical information will allow other services who use this same clinical computer system, eg District Nurses, to access your medical record but ONLY if they have need to do so for your clinical care.

Do you consent to the sharing of data recorded here with any other organisations that may care for you? *

Yes No

Do you consent to the viewing of data by this organisation that is recorded at other care services that may care for you, and where you have agreed to make the data shareable? *

Yes No

National Data opt-out

Information about your health and care helps the NHS to improve your individual care, speed up diagnosis, plan your local services and research new treatments. In May 2018 strict rules about how this data can and cannot be used were strengthened. You can choose whether your confidential patient information is used for research and planning. To find out more visit nhs.uk/your-nhs-data-matters Leaflets on all the above data sharing models can be obtained from reception.

Signature

Signature *

Date in format **/**/**** *

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University Student Questionnaire

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