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            What forms are available to use?

            Modified on Tue, 20 Aug at 3:59 PM

             Forms previews


            Our clinical forms tool allows you to send patients pre-defined forms for their completion. Forms can also be completed on behalf of the patient via telephone, meaning choice of channel doesn’t affect quality of service.


            Forms can also be used to configure custom patient pathways, for example you can configure a button in the patient portal which they can click to immediately raise a request using a Sick note form.


            We currently have the following forms available to use. If there is a form which is not currently active for your practice, but you would like to try, please just let us know.


            Important notice: The below forms are for example only and are not to be used by, or shared with patients. If you would like a form added to your system, please ask your Account Manager (or get in touch via the 'Help' button).

            Forms Navigator

            Please select one of the options below to be taken to relevant forms of that type:  


            Acute Requests

             Admin Query

             Application for online services

             Care Homes

             Children

             Chest Problems

             Medication

             Men's Health

             Mental Health

             Non-Acute Queries

             Nurse/HCA

             Sick/fit note request

             Smoking

             Suspected UTI

             Travel

             Women's Health

            Acute Requests


            Acute request form alternative EG8
            		https://surveyjs.io/published?id=e5e28447-648e-4563-94aa-bdc11281b158
            Acute request form alternative EG7https://surveyjs.io/published?id=42b3c0b0-5fc7-4d66-b539-5c6b14240349


            Admin Query


            General admin query EG14https://surveyjs.io/published?id=25669168-6894-45df-8e2d-dc6c68aefdc4
            Change of details EG39https://surveyjs.io/published?id=d41ff203-9dea-4527-8bb7-755e2081dfd6
            I have received a letter or email EG80https://surveyjs.io/published?id=86460e3e-f245-4f13-825c-4ac329283139
            Appointment cancellation  EG23https://surveyjs.io/published?id=4da7f70c-6ee8-4635-a910-8755365aba7d
            General triage EG70https://surveyjs.io/published?id=e504bfcb-7c66-4d38-9bc2-aee800afd8fd
            Follow-up appointment request EG69 https://surveyjs.io/published?id=8afab01f-8e32-46b8-8398-4abd4ad73eba
            Medical Reports/ Letters request EG86https://surveyjs.io/published?id=f161368d-5c90-4397-beac-9c3b2ab0dce3
            Referral query EG133https://surveyjs.io/published?id=6dc2fd67-5f2a-4940-90b5-d60c0b12c866
            Results follow up EG140https://surveyjs.io/published?id=b4369e5d-a600-4043-af89-06674326b4a0
            Results request EG142https://surveyjs.io/published?id=e44b16c6-ffae-4ff8-a210-1f0968b9b4ff


            Application for online services

            Online access application EG22https://surveyjs.io/published?id=6de6a84a-d2d6-46a7-add4-5f6c0603928a
            EPS registration form EG60https://surveyjs.io/published?id=2de03f10-c0af-42c2-bec9-5d741f45068f


            Care Homes


            Care Home Contact Form EG37https://surveyjs.io/published?id=db78c84b-5827-4d15-9218-771b0e175aba


            Children


            Febrile Child EG65https://surveyjs.io/published?id=55ea508c-4a5e-45e8-ae9f-a65ae8917fed
            Chest Infection in <12y EG65https://surveyjs.io/published?id=94d6a69b-c3e1-4a92-a585-baf85b4b831f
            Chest Infection in >12y EG65https://surveyjs.io/published?id=745550d8-9e57-435b-ab60-fcc637b73a73
            Throat Infection EG180https://surveyjs.io/published?id=46aa9ab0-12ae-44db-8ba4-646b00c63ad2


            Chest Problems


            COPD Assessment Test (CAT) EG53 https://surveyjs.io/published?id=e904a51e-2637-40a2-9416-5caaaddd040e
            Exacerbation of COPD / Chest infection EG63https://surveyjs.io/published?id=1d38aad5-ebec-48f1-b7a5-fa375b42e558
            Suspected chest infection EG170https://surveyjs.io/published?id=b7d88b73-6463-4ce5-9fa9-e4253b5e39d3


            Medication


            Medication review https://surveyjs.io/published?id=f0f76381-3b99-4340-a80a-d75abbfc5291
            Medication Review alternativehttps://surveyjs.io/published?id=2bf7c60b-3e2f-4dd4-89ec-e5c3393a5b23
            Medication request https://surveyjs.io/published?id=a8fb5207-3ef3-44db-a6ac-3c99c62de923
            Prescription request EG125https://surveyjs.io/published?id=727c6f1f-0f1b-41b4-8e7a-9c73ab615a42
            Prescription request (Non-England) EG126https://surveyjs.io/published?id=3f86f3d5-2948-4e03-b767-575836bffb21


            Men's Health


            Sexual Health Inventory for Men (SHIM) EG154https://surveyjs.io/published?id=fab3c9c0-0e4d-498e-aed3-b8eb687b7ea5
            PSA requested EG131https://surveyjs.io/published?id=35cf1fab-2df4-4c96-84ed-ee732211eafc
            IPSS - International Prostate Symptom Score EG84https://surveyjs.io/published?id=3d7b5d03-4aad-4528-b9f6-a9e0177bce36


            Mental Health


            Adult ADHD referral EG15https://surveyjs.io/published?id=2651eab3-b824-4f73-8b99-e23a28206fd3
            Adult autism referral EG17https://surveyjs.io/published?id=f4f5253a-e24b-4af3-ad37-f79d6ef9460d
            GAD-7 EG71https://surveyjs.io/published?id=51f931bd-ff4d-49e0-b6d8-cf91a5e9ac2c
            PHQ-9 EG119https://surveyjs.io/published?id=727a3d6a-c3e2-4bf9-8b15-dacdf0db326d
            Antidepressant review EG21https://surveyjs.io/published?id=4bd38288-5ac0-4ff2-a126-c2e0ed204be4
            The Short Warwick–Edinburgh Mental Well-being Scale (SWEMWBS) EG179https://surveyjs.io/published?id=6b980e5e-b119-401d-8339-c7568ad540a7


            Non-Acute Queries

            Routine Request Form (Choose clinician) EG147
            		https://surveyjs.io/published?id=8c983744-95c6-4749-8337-475a067110d9
            Routine Request Form (No clinician) EG146
            		https://surveyjs.io/published?id=154def44-3132-4722-afe4-6d4e53c30c47
            Cellulitis EG38https://surveyjs.io/published?id=fa3acb7e-f412-428b-bdf3-2b2503964b9b
            Constipation EG44https://surveyjs.io/published?id=7a836a21-99ed-46c0-9dba-cfdc7fe412fb
            Sinusitis - 12 years and over EG160https://surveyjs.io/published?id=ba13568b-4171-4f90-a1e0-779ef400a55d
            Headache EG72https://surveyjs.io/published?id=4a4a8ada-b996-4aff-9074-2e2a68e90438
            ME/CFS Referral EG85https://surveyjs.io/published?id=9715de79-44e9-453c-9b16-8b6b404ebac0
            Tiredness EG181https://surveyjs.io/published?id=deb250a1-77d9-41fd-a46f-1cceb3827c77
            Ear Infection EG56https://surveyjs.io/published?id=c18222a3-d004-436d-873b-3dbeedc895e1
            Oxford Hip Score EG113https://surveyjs.io/published?id=10457336-f699-425e-841f-610fb0c1701c
            Oxford Knee Score EG114https://surveyjs.io/published?id=43b84c69-0947-449a-8a44-7c24e25168e6
            Asthma Control Test EG24https://surveyjs.io/published?id=54407ca9-a99a-4beb-9adf-c2a647eb6f4e
            AUDIT - Alcohol Screening Tool EG25 https://surveyjs.io/published?id=db9ad7dd-3c68-43f8-80f8-adf534d07512
            Fast Alcohol screening test (FAST) EG64
            		https://surveyjs.io/published?id=617226d0-6427-4ffc-ba7b-5bb045caf9a8
            Back Pain CES Screening EG27https://surveyjs.io/published?id=dd4f3600-b970-4441-a5a1-75fc0e2e9c83
            Wheelchair referral EG167https://surveyjs.io/published?id=321f1e6d-73c3-4159-8c68-d4781b417a3b
            STarTBack EG168https://surveyjs.io/published?id=64add01a-0603-4af2-b2db-2343a8eb0d1f
            Dietician Referral Requested EG193https://surveyjs.io/published?id=1192ba1c-9555-4fa1-9100-0f6f757561de
            Drink Diary EG55https://surveyjs.io/published?id=69e4d1c1-7220-4c7c-be06-38c03951dd6f
            Epilepsy review EG59https://surveyjs.io/published?id=f38b6570-a9d6-45f3-98fc-6ee32e223969
            Epworth Sleepiness Scale (Adult) EG61https://surveyjs.io/published?id=dc4f9f75-b6ce-4c7b-bdf6-fede8b91375a
            PPI Review EG122
            		https://surveyjs.io/published?id=0a9ba0d0-bf08-4e12-b63e-5b0a9ed53060
            Psoriasis Epidemiology Screening Tool (PEST) EG205
            		https://surveyjs.io/published?id=dd70c401-f0db-4119-a70e-04e910532612
            MSK
            		https://surveyjs.io/published?id=6abd05d7-3926-4f88-8c24-0e37e0f37c16


            Nurse/HCA


            Nurse/Blood test appointment EG106https://surveyjs.io/published?id=31f9f2f4-0a3a-4cdb-8b31-51513f73b07a
            Nurse/HCA appointment request https://surveyjs.io/published?id=f29a14cf-283d-42b9-9c1d-a4f7e9b88d98


            Sick/fit note request 

            Fit Note Request EG158https://surveyjs.io/published?id=4f5fda03-9d91-4c20-b33e-78e779d69d4c
            Sick/fit note request alternative 1  EG156https://surveyjs.io/published?id=19c06978-71ca-44c9-b0fb-06f02fd7eaa9
            New sick note only EG102https://surveyjs.io/published?id=063194e0-54dd-42e9-8307-5a5b6748aedd
            Repeat sick note only EG135https://surveyjs.io/published?id=2796838d-6c87-4a47-977e-c464ef516d98


            Smoking


            Smoking Review EG162https://surveyjs.io/published?id=354b94a5-5518-454c-bc02-29fb4f37f802


            Suspected UTI


            UTI Questionnaire https://surveyjs.io/published?id=2006ab1c-fa2c-4754-9723-9a0af9ee3556
            Urine infection form EG184https://surveyjs.io/published?id=18e6dce0-1caf-476f-b2fb-2019597815a0


            Travel


            Travel Vaccinations/ Risk Assessment Form EG182https://surveyjs.io/published?id=d7ad5e81-02dc-4c54-8ff6-f2d82d8ec996


            Women's Health


            Women's Health Questionnaire EG204 https://surveyjs.io/published?id=a590e4d0-be1d-4474-a4b5-25c0d4618aa6
            Breast lump EG33https://surveyjs.io/published?id=1441cf4f-30f7-4d26-b676-b2b59778b2da
            HRT Annual Review EG74https://surveyjs.io/published?id=1808594d-c8f7-4d18-acb7-70222027476b
            Alternative HRT Questionnaire EG207https://surveyjs.io/published?id=66928dfc-51d3-4635-927f-be9bbe519c45
            Period Delay (over 15+) EG116https://surveyjs.io/published?id=6c3e229e-b96a-48a2-bbac-21f94e61d985
            Request for medication to delay period EG136https://surveyjs.io/published?id=9c218d56-55e3-4eea-bfe5-8942ab8569e6
            Menopause Symptom Questionnaire EG95https://surveyjs.io/published?id=1e4794fa-fa87-4e7f-94e7-529a1c599516
            Contraceptive Pill Checkhttps://surveyjs.io/published?id=83fbbd2f-67c7-4d2d-8cd5-0b95bbc2afac
            Combined contraceptive pill review EG42https://surveyjs.io/published?id=c742ca96-d21c-4ca3-a17e-9aee6dab3345
            Mother's 6-Week Postnatal Check EG97https://surveyjs.io/published?id=a599ed4c-9cc4-46d3-a89b-d073cf0be5a4
            Pregnancy risk factors EG124https://surveyjs.io/published?id=97433617-ccd4-4551-bb7a-27fd14ceb734
            Progesterone only pill review EG129https://surveyjs.io/published?id=8012d224-4d7f-4950-903a-b5251df0b403
            Subfertility EG169https://surveyjs.io/published?id=811cf971-32ea-4e98-9987-3d9f9f5609b7
            Breast cancer risk EG31https://surveyjs.io/published?id=8c705e56-35aa-47c4-aaf2-c7c8f52b652a
            Intrauterine Device (Coil) request EG83
            		https://surveyjs.io/published?id=4b765e54-378a-4abb-9c76-a8d777d6df6f
            Contraceptive Implant request 
            		https://surveyjs.io/published?id=81ab9267-fa6a-4821-bbf6-fff11ca0ce19



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