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Form for Patients to fill in for a request for a sick note

Employees can now get a fit note from the following healthcare professionals: GP or hospital doctor registered nurse occupational therapist pharmacist physiotherapist The healthcare professional needs to assess the employee’s fitness for work before giving a fit note. At Portcullis Surgery we have now authorised all our nurses to be able to provide sick notes however, in order to obtain a sick note all patients must fill in the following form. Please fill in this form to the best of your ability as it will form part of your assessment. Fit notes are free if the employee has been ill for more than 7 days when they ask for one. If a sick note is required by an employer even though the employee has been ill for less than 7 days we will charge a fee of £20 for this service. Employees will need to discuss this with their employer and ask them for reimbursement of any fees charged by the practice.

Name(Required)

First Last

Date of Birth(Required)

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Mobile or landline phone number (we prefer mobile phones if possible)(Required)

Please describe what medical conditions you have that stop you from being able to work in the paragraph below(Required)

When did your medical problem (s) that stopped you from working start? Please give aproximate dates.(Required)

Explain exactly how long you think you will need off work. We need start and end dates please. (Please note the maximum time for a sick note we can give is 3 months)(Required)

Are you requesting an extension of a previous sick note? If you are, please write down the date of expiry of your previous sick note. (Sick notes can now be requested upto 2 weeks prior to the expiry of a previous sick note. We will usually be able to provide a sick note within 5-7 working days of receiving your request so please request your sick note with plenty of time so that you do not run out)

Have you seen a clinician (Doctor, Nurse or ANP) at the practice already about the medical condition (s) stopping you from working? If you have, please TICK the name of the clinician who you feel knows you well enough to give you a sick note in the space below.(Required)

Would you be able to return to work earlier with amended duties (such as light duties) or reduced hours? (please explain)

Please describe the symptoms you get from your medical problems (please describe each problem)(Required)

What treatment are you on for your medical condition (s)

How far can you walk, do you have any mobility problems?

Does any of your medical condition stop you from travelling to work? Please explain.

Does any of your medical condition make communication with others difficult or impossible? Please explain.

Does any of your medical condition stop you from being able to dress yourself, cook for yourself, wash or bathe yourself or manage your own toileting? Please explain.

Does any of your medical condition stop you from making simple decisions or managing your own health condition? Please explain.

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