Before your 10-minute consultation

Your symptoms.
Your key details.

Complete this short form before your appointment so we can spend the call discussing your assessment and advice. Brief answers are enough.

About 3 minutes · This form does not book an appointment.

For planned consultations only. This form is not continuously monitored. For a life-threatening emergency call 999; for urgent medical help in the UK use NHS 111. Do not wait for a reply to this form.

Required fields are marked .

About you

Full name

Date of birth Your age is calculated from your date of birth.

Gender optional

Appointment date if already booked

Phone number

Email address

Your health and current problem

Current complaint Which body part and side? When did it start, and how does it affect you?

Past medical history Relevant conditions or operations. Write “none” or “unsure” if appropriate.

Current medications Names and doses if known, including blood thinners. Write “none” or “unsure”.

Allergies Name and reaction, or “none known” / “unsure”.

Any imaging? X-ray, MRI, CT or ultrasound: date, hospital and whether a report is available. Write “none” if you have not had imaging.

GP / usual doctor optional

Please describe your imaging here. Reports and scans cannot be uploaded through this form; a suitable transfer method can be agreed with the practice. Do not include passwords or private image-sharing links.

Your details are used to prepare for and document your consultation. They are kept in the practice’s private consultation records, and are not published on this website. See the patient privacy notice for how your information is handled and your rights.

I have read the patient privacy notice and the information I have provided is accurate to the best of my knowledge.

Your answers are only saved when you submit. They are not saved as a draft on this device.

Your symptoms.Your key details.

Thank you.

Your symptoms.
Your key details.