Essex House Surgery
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Stage
MEDICAL_WARNING
REPORTER
REQUEST_DETAILS
PROXY_DETAILS
PATIENT_DETAILS
SUMMARY
Call 999 or go to A&E if you have any of the below symptoms:
Signs of a heart attack
(chest pain, pressure, heaviness or tightness across the chest)
Signs of a stroke
(face dropping on one side, cannot hold both arms up, difficulty speaking)
Sudden confusion
(unsure of own name or age)
Suicide attempt
(by taking something or self-harming)
Severe difficulty breathing
(not being able to get words out, choking or gasping)
A serious injury
(e.g. after a serious accident)
Heavy bleeding
(spraying, pouring or enough to make a puddle)
Severe injuries
(after a serious accident or assault)
A seizure or fit
(shaking, jerking, or unconscious & can’t be woken up)
Sudden, rapid swelling
(of the lips, mouth, throat or tongue)
Acknowledged date time
Who is the request for
Who is the request for?
None
Me
Someone else
First name
Last name
Relationship to patient
First name
As it would appear on their medical records
Last name
Postcode
Date of birth
Date of birth
Month
Year
For example, 14 9 1993
Please describe the problem
Uploaded attachments
I have none of these