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                                                                            Student Occupational Health
                                                                            The University of Salford
                                                                            Room LG20, Peel Building
                                                                            Salford, Greater Manchester
                                                                            M5 4WT. United Kingdom

                                                                            T +44(0)161 295 6273
                                                                            F +44(0)161 295 5983
                                                                            www.salford.ac.uk




                General Practitioner Questionnaire
Dear Doctor

Your patient has applied for a place on a health related course at the University and has
given your name as their General Practitioner.

We are required to make enquiries about their past medical history to ascertain suitability
to undertake this training. We would ask you to consider the physical and psychological
suitability of your patient to enter a demanding career. The applicant will also complete a
health declaration and will be assessed in Student Occupational Health but your help
would be appreciated. The applicant will not be rejected on the basis of an adverse
report from you alone.

Please complete the form as fully as possible.

Yours

Student Occupational Health


PERMISSION OF STUDENT

Before signing please refer to the notes on the back page.

I herby confirm that I have been informed of my rights under the ‘Access to Medical
Reports Act 1988’ and give my consent to my General Practitioner and any other health
professional to complete the form overleaf.

I do / do not wish to see any such report before it is sent (Delete as appropriate)


Course _________________________________________

Print Name ______________________________________ D.O.B ________________

Signed [Student]   ________________________________ Date _________________


Please note that this form must be completed and signed by your GP before your
medical. Failure to do so will result in medical clearance being significantly
delayed.

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Clients Name _______________________________________ D.O.B. _____________

How long have you held the medical records of this person?

From what date do they commence?

How often has the applicant consulted you?
       In the past 1 month?

       In the previous 12 months?


If you answer yes to any of the following please give brief details including dates

                            If Yes,   If No,
Has the applicant ever      please    please    If you have ticked ‘Yes’, please give
had or suffering from:      tick      tick      details and dates
                            below     below

Any significant physical
illness/problems?

Any episodes of
depression, anxiety,
stress related illness?
Any psychotic or
hallucinatory episodes?
Any attempts to self
harm, over dose, suicide
attempts, however trivial
it may have seemed
Any other
psychological/personality
problems, behavioural or
eating disorder etc
Any prolonged periods of
illness, especially if
causing time off
work/college/school?


Signed [Doctor] _______________________________ Date ____________________
                 PLEASE AUTHENTICATE WITH PRACTICE STAMP




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                                                                            Page 3 of 4

              NOT APPLICABLE FOR SOCIAL WORK STUDENTS

    Clients Name _______________________________________ D.O.B. _____________


                            IMMUNISATION RECORD

                         Date of        Where performed
                                                                         Results
  Immunisations       Immunisation or   if not at GP e.g.
                                                                      If applicable
                         Disease             OH etc

                                                            Reading
Mantoux / Heaf Test
                                                            Scar Present Yes/No
B.C.G.
                                                            Antibody Test Yes/No
                                                            Immune Yes/No/ Not Known
Measles
                                                            Please supply copy of Blood
                                                            results
Mumps
                                                            Antibody Test Yes/No
Rubella                                                     Immune Yes/No/ Not Known
                                                            Please supply copy of Blood
                                                            results
                                                            Antibody Test Yes/No
M.M.R.                                                      Immune Yes/No/ Not Known
                                                            Please supply copy of Blood
                                                            results
                                                            Antibody Test Yes/No
                                                            Immune Yes/No/ Not Known
Chicken Pox
                                                            Please supply copy of Blood
                                                            results
                                                            Antibody Test Yes/No
Hepatitis B                                                 Date of last Test

                                                            Results

                                                            Surface Antigen Test Yes/No
                                                            Date of Test

                                                            Results

                                                            Please supply copy of Blood
                                                            results

    Signed [Doctor] _______________________________ Date______________________
                     PLEASE AUTHENTICATE WITH PRACTICE STAMP




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                                                                        Page 4 of 4


Access to Medical Reports Act 1988

In order to assess your health and fitness to practice we need to apply for a
medical report from your General practitioner. In order to do this we require your
informed consent. Please read the following information before giving your
permission on the front of this form.

You have the right to refuse to consent to our applying for any or all of these
reports.

You have the right to notify us if you wish to see any medical reports before it is
sent to us or alternatively you may request access to the medical report by
notifying the doctor preparing it. In both cases you will have 21 days in which to
make arrangements with the doctor preparing the medical report to see it.

If you exercise your right to see a report before it is sent to us you may then
instruct the doctor to withhold that report from us. You may ask the doctor in
writing to amend any part of the report if you consider it to be incorrect or
misleading.

A doctor may decline to let you see all or part of a report to which you have
requested access if he considers that this would be inappropriate. In these
circumstances you would be asked for your consent before he can release it to
us.

Each doctor must keep a copy of the report he prepares for six months, during
which time you may ask to see it.

Refusing consent, or access to prepared reports, may delay a decision in your
case or mean that conclusions are reached without the full facts being available.




Version 5 20.02.12/IQ                                                 12.01.11/RB

				
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