Portcullis Surgery

Portcullis Surgery

Portcullis Lane, Ludlow, SY8 1GT

Current time is 11:25 - We're open

NHS

Telephone: 01584 872 939

Fax: 01584 879 031

portcullis.surgery@nhs.net

Heath Check Questionnaire 2021

Dear patients we have produced this questionnaire in order to update our records and also try and identify patients who may have missed essential health checks or screening tests in the last year during the pandemic.

We will be handing out questionnaires for patients to fill in while we carry out our Covid Booster clinics but we have published the questionnaire online also so that patients can fill it in if they wish online.

You can also download and print it off in the link below and send it to us by email to portcullis.surgery@nhs.net

Questionnaire for patients in the Covid Booster clinic

Many thanks

 

Health Check Questionnaire for all our patients coming for Covid Boosters

Dear patient Thank you for attending the Covid Booster or Flu clinic. We would be grateful if you could fill in this short questionnaire. If you wish you can fill it in at home and then hand it in at reception at a later date either in paperform or online.
Name(Required)
DD slash MM slash YYYY
Smoking: Do you currently smoke?
Do you consider yourself overweight or obese?
Bowel screening for cancer: All patients between 56-76 years of age are automatically sent a screening test every 2 years. If you are over 75 years you can also request one every two years. The screening test is called a Faecal Occult blood test and checks for blood in your pooh. Are you over 56 years old and have you sent a bowel screening test in the last 2 years?
Health Check All adults over from 45 to 74 years, without pre-existing conditions, are invited to a health check every 5 years in order to check their BP and do a test for cholesterol and diabetes. Have you been invited to a health check in the last 5 years?
Falls prevention: How many falls have you had in the last year?
Are you worried about your balance or frequent falling?
Memory and low mood: Are you concerned about your memory and forgetfulness?
Are you worried you may be depressed or feel lonely quite frequently?
Ladies ONLY - Breast screening for cancer: All women between 50-71 years of age are automatically sent a screening test every 3 years. If you are over 71 years you can also request one every three years. The screening test is called a mammogram. Have you had a mammogram test in the last 3 years?
Ladies ONLY - Cervical screening for cancer (smear test) All women between 24.5 and 49 years of age are automatically sent a screening test every 3 years. Women between 50 and 64 years are sent an invite every 5 years. There is no need for smears if you are older than 64 years of age unless your previous tests were abnormal. Are you overdue for a smear test?
This field is for validation purposes and should be left unchanged.

Opening Times

  • Monday
    08:30 until 20:00
    6-8pm Pre-booked appointments only.Call 111 for advice OOH
  • Tuesday
    08:30 until 20:00
    6-8pm Pre-booked appointments only.Call 111 for advice OOH
  • Wednesday
    08:30 until 20:00
    6-8pm Pre-booked appointments only.Call 111 for advice OOH
  • Thursday
    08:30 until 18:30
    Call 111 for advice OOH
  • Friday
    08:30 until 20:30
    Open 1-2 Fridays a month. 6-8pm Pre-booked appointments only.Call 111 for advice OOH
  • Saturday
    08:30 until 12:30
    Open 1-2 Sat per month Pre-booked appointments only. Call 111 for advice OOH
  • Sunday
    CLOSED
    Call 111 for advice OOH