Kirklees Primary Care Trust and Mid Yorkshire NHS Trust What affects your health? Name/ Patient no D.O.B Address Phone number Condition/s Referred from Date
Below is a check list of things that can affect a person’s health. We would like to provide you with as much support and information as possible. We have developed two lists below to help you highlight anything that is a concern for you. Please tick the boxes below that are important to you and that you might need help with. We will use these lists to help provide you with the right information or to signpost you to the right service. Please tick the boxes below that are important to you and you need help with Do you have any problems or difficulties with: 1. ٱ My ability to cope with my limits and the things that stress me. 2. ٱ Coping with anxiety, or anger and depression. 3. ٱ Being able to socialise. 4. ٱ Coping with daily activities e.g. washing, cooking cleaning. 5. ٱ Feeling guilty or blaming myself for this condition. 6. ٱ The level of personal support I receive. 7. ٱ My carer understanding my condition. 8. ٱ My carer needing more help or support. . 9. ٱ Trying to stop smoking tobacco. 10. ٱ Eating the right types of food. 11. ٱ How physically active I am. 12. ٱ Any use of Illegal substances including mine and others e.g cannabis etc 13. ٱ How much alcohol I am drinking. 14. ٱ My sexual activity. 15. ٱ My level of reading, writing and coping with numbers. 16. ٱ My ability to use English. 17. ٱ My ability to physically access services e.g. steps etc 18. ٱ Money worries e.g. difficulty in paying bills. 19. ٱ Any problems with housing. 20. ٱ Getting to local shops or leisure facilities 21. ٱ Concerns about the impact of my job on my health or vice versa 22. ٱ Maintaining or improving my oral health 23. ٱ Anything important to you including hobbies, leisure or social events. Please describe: 1
If you ticked more than 3 areas of your life, please circle the 3 most important to help with at present.
Kirklees Primary Care Trust and Mid Yorkshire NHS Trust Now thinking specifically about your long term condition Please tick the boxes below that are important to you and you need help with Do you have any problems or issues that you need any help or support with: 1. ٱ Understanding what my condition is? ٱ What might happen in the future? 2. ٱ The tests used to assess or monitor my condition? ٱ Which should I be doing? 3. ٱ When should I have routine tests? 4. ٱ The medication and therapies available for my condition. 5. ٱ The medication I take for my condition. ٱ • Their side effects. ٱ • When to increase or decrease my medication. ٱ • What happens if I don’t follow the instructions? 6. ٱ Managing physical symptoms due to my condition such as E.g. breathless for respiratory. 7. ٱ My sleep being disturbed by symptoms 8. ٱ Monitoring my symptoms regularly 9. ٱ Managing bodily pain symptoms. 10. ٱ Managing relapses. 11. ٱ Knowing who to contact if my condition gets worse or goes out of control 12. ٱ Booking appointments. 13. ٱ Travelling to appointments. 14. ٱ Health professionals understanding me and my condition and helping me to cope 15. ٱ Where to get information about my condition. Again: if you ticked more than 3 areas regarding your condition then please circle the 3 most important to help with at present. Thank you for helping us to understand your needs. Please remember to take this with you when you go for your appointment at the clinic
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