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Health Promotion Service Cornwall and Isles of Scilly

Easy Read self referral form

Questions marked with * need to be filled in
Your name Your name *
Are you male or female? Are you male or female? *

Do you have a disability? Do you have a disability? *
Do you have a learning disability? Do you have a learning disability? 
Do you have an annual health check at your GP surgery? *<br /><br />You can get your health checked every year. This is from when you are 14 years old. This is to make sure that you stay healthy. Do you have an annual health check at your GP surgery? *

You can get your health checked every year. This is from when you are 14 years old. This is to make sure that you stay healthy.
 

Do you have a physical disability? Do you have a physical disability? 
Do you need information in a special way? Like large print or Easy read Do you need information in a special way? Like large print or Easy read 
What are your communication needs? What are your communication needs? 
Where do your live? Where do your live? *
What date were you born? What date were you born? *
Have you had your free health check at your GP Surgery? *<br /><br />This is your chance to get your health checked. This is from when you are 45 years old. This is to make sure that you stay healthy. Have you had your free health check at your GP Surgery? *

This is your chance to get your health checked. This is from when you are 45 years old. This is to make sure that you stay healthy.
 

What is your phone number? What is your phone number? 
What is your email address? What is your email address? 
Where is your GP Surgery Where is your GP Surgery *
What support do you need? Tick which ones you would like help with

What support do you need? Tick which ones you would like help with

 
 
How did you hear about Health Promotion Service? How did you hear about Health Promotion Service? 
Are you pregnant? Are you pregnant? 
Consent to contact me and to keep my personal information

Consent to contact me and to keep my personal information

It is OK for you to contact me It is OK for you to contact me *
What is the best way to contact you?

What is the best way to contact you?

By phone By phone 
By email By email 
By letter By letter 
It is OK for you to contact my GP It is OK for you to contact my GP *
As a health record this form will be retained in line with the NHS Retention and Destruction Schedule. By submitting this form you consent to us holding this information.
More information

More information

Anything else we need to know about you? Anything else we need to know about you?