RAPID-P : Health Questionnaire

Select Your Practice

Please select your GP practice by typing any part of your GP practice's name or address, or the start of the postcode, into the box below. As you type a list of practices will appear.

For example, if you are registered at the "Westcliffe Medical Centre, Shipley, BD18 3EE", you could choose to enter 'Westcl', 'cliffe', 'Shipley' or 'BD18' to refine the list down to a manageable level.

The more characters you type the shorter, and more accurate, the list will become.

Then simply scroll down and click on your practice's details to make your selection.

If this page has been translated into another language it will probably work best if you stick to postcodes.

When selecting your current GP practice, from the list of results, please read the full address to ensure you select the correct practice.

Start typing in the box above to find GP practices, and medical centres, who's details contain the typed characters. The more characters, the more refined the results.

About you

Your age:

Are you 55 years of age or older?

About your general health and medical history

Question 1:

Have you been diagnosed with any form of heart disease?

Question 2:

Have you been diagnosed with diabetes?

Question 4:

Have you had a transplant?

Question 5:

Do you have a pacemaker?

Question 6:

Have you been diagnosed as having issues with your mental health?

Question 7:

Are there any medications your specialist / GP has told you to mention if seeing another doctor?

About your symptoms

Question 8:

Do you suffer from regular problems with indigestion?

Question 9:

Have you lost weight recently?

Question 10:

Recently, have you had times when you felt sick (nauseous)?

Question 11:

Have you been vomiting recently?

Question 11a:

If you have answered Yes to Question 11, has it ever contained blood?

Question 12:

Does food get stuck when you are swallowing?

Question 13:

Do you regularly suffer from reflux / acid reflux?

Question 14:

Do you suffer from upper stomach pain?

Question 16:

Do you experience any other symptoms?

About this questionnaire

Question 17:

Did you understand all of the questions?

Question 18:

Is there any other information you would like to mention?


IMPORTANT

If you have noticed blood in your vomit or blood in your stools (the stools may appear black and tar-like), please seek urgent medical attention; either by calling your GP or dialling 111.