NHS

12 High Street, Fochabers, IV32 7EP

Telephone: 01343 820247

Fax: 01343 829930

fochabersadministrator@nhs.net

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Non NHS Medical Declaration

To be completed by anyone requiring a medical examination or the completion of a medical pro forma, in support of their non-NHS request, from a 3rd party agency e.g. HGV/PSV, Insurance application, application to take part in arduous activities within or outwith the UK.

Pre-Medical Examination declaration

This is to be completed by the patient and is to accompany their application for non-NHS services. This information will be treated in the strictest confidence and is to provide the GP with enough base evidence for a decision to be made in support of your request:
  • Details of the person making the medical declaration
  • e.g. son or daughter, or a family member who is unable to complete the form themselves.
  • Please provide the GP with as much information as possible
  • Declaration Questionnaire (21 Questions)

    To be completed by all applicants
  • Have you ever suffered at any time from diseases of the heart and circulation including high blood pressure (or taking tablets for high blood pressure), angina, chest pains or palpitations?
  • Have you ever had heart surgery?
  • Have you ever had significant bleeding or blood disorders?
  • Have you ever suffered from or had to take medication for Asthma?
  • Have you ever had collapsed lung or pneumothorax?
  • Have you ever had any other chest or lung disease or problems?
  • Have you ever suffered from blackouts, fainting or recurrent dizziness?
  • Have you had regular ear problems in the last 10 years?
  • Do you have an ileostomy, colostomy, or ever had a repair of the hiatus hernia?
  • Have you ever had epilepsy or fits?
  • Have you ever had recurrent migraines?
  • Have you ever had any other disease of the brain or nervous system (including strokes or multiple sclerosis)?
  • Have you had a head injury with loss of consciousness in the last five years?
  • Have you ever had any back or spinal surgery? Or had any serious back problems?
  • Have you ever had any mental or psychological illness of any kind, fear of small places, crowds, or panic attacks?
  • Have you ever had any problem with alcohol or drug abuse in the last five years?
  • Do you have diabetes?
  • Are you taking any prescribed medication (except the contraceptive pill)?
  • Are you currently receiving medical care or have you consulted a doctor in the last year other than for trivial issues e.g. common cold or minor injury?
  • Have you ever been refused any medical certificate or life insurance, or been offered special terms?
  • Have you ever had, or been treated for, decompression illness?
  • Please consider giving the GP any additional information that will help process your request.
  • To be signed by the requesting patient