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SECTION B - Screening questionnaire to be completed once for each entitled dependant of the service person.Please ensure that ALL sections are completed. Failure to do so may delay the processing of your questionnaire. This information will be used to create you a confidential electronic medical record that can be used during your assignment overseas.Details of the Dependant We may need to contact you if we require further information. Please indicate below how you would like to be contacted (we will contact the parents of children under 18):Email FORMDROPDOWN Mobile FORMDROPDOWN a.Surname FORMTEXT ?????b.Forename FORMTEXT ?????c.Title FORMTEXT ?????d.Date of Birth FORMTEXT ?????e.Sex FORMTEXT ?????f.NHS Number FORMTEXT ?????g.Email FORMTEXT ?????h.Mobile Phone FORMTEXT ?????i.Height FORMTEXT ?????j.Weight FORMTEXT ?????Contact AddressContact address a.House No. / Name FORMTEXT ?????b.Street / Road Name FORMTEXT ?????c.Town / City FORMTEXT ?????d.Postcode FORMTEXT ?????e.Home Tel No. FORMTEXT ?????Medical Officer / GP Detailsa.Med Centre Name FORMTEXT ?????b.GP Name FORMTEXT ?????c.Telephone FORMTEXT ?????d.Email Address (if known) FORMTEXT ?????e.Address FORMTEXT ?????Dental Officer / Dentist Details - Dental requirements will be forwarded to the SDO at assignment location or the overseas dental dept for assessment.a.Dental Centre Name FORMTEXT ?????b.Dentist Name FORMTEXT ?????c.Telephone FORMTEXT ?????d.Email Address (if known) FORMTEXT ?????e.Address FORMTEXT ?????f.Details of any outstanding dental work required or ongoing: FORMTEXT ?????Your health and functional ability:Cardiovascular (for all sections tick ‘yes’ or ‘no’)Have you previously or are you currently suffering from any of the following:YesNoa.Heart attack, angina or other heart disease? FORMCHECKBOX FORMCHECKBOX b.Heart murmurs or abnormal heart rhythm, arrhythmia? FORMCHECKBOX FORMCHECKBOX c.High blood pressure? FORMCHECKBOX FORMCHECKBOX d.Deep vein thrombosis or other circulation problem? FORMCHECKBOX FORMCHECKBOX If YES to any of the above please give details including a diagnosis, an indication of date and duration etc (e.g. when condition developed, severity, effects and treatment / medication). Please also include any relevant clinical letters. FORMTEXT ?????Respiratory Have you previously or are you currently suffering from any of the following:YesNoa.Any breathing problems? FORMCHECKBOX FORMCHECKBOX b.Asthma or other lung disease including Tuberculosis? FORMCHECKBOX FORMCHECKBOX c.Spontaneous or traumatic Pneumothorax / Haemothorax (collapsed lung)? FORMCHECKBOX FORMCHECKBOX d.Have you ever suffered from COPD, Chronic Bronchitis, Emphysema? FORMCHECKBOX FORMCHECKBOX If YES to any of the above please give details including a diagnosis, an indication of date and duration etc (e.g. when condition developed, severity, effects and treatment / medication). Please also include any relevant clinical letters. FORMTEXT ?????NeurologicalHave you previously or are you currently suffering from any of the following:YesNoa.Epilepsy, fits, blackouts, fainting or loss of consciousness? FORMCHECKBOX FORMCHECKBOX b.Chronic headache or migraine? FORMCHECKBOX FORMCHECKBOX c.Diseases of the nervous system e.g. Stroke, Multiple Sclerosis? FORMCHECKBOX FORMCHECKBOX If YES to any of the above please give details including a diagnosis, an indication of date and duration etc (e.g. when condition developed, severity, effects and treatment / medication). Please also include any relevant clinical letters. FORMTEXT ?????EndocrineHave you previously or are you currently suffering from any of the following:YesNoa.Diabetes FORMCHECKBOX FORMCHECKBOX b.Thyroid Disease FORMCHECKBOX FORMCHECKBOX c.Adrenal Disease e.g. Addison’s Disease FORMCHECKBOX FORMCHECKBOX If YES to any of the above please give details including a diagnosis, an indication of date and duration etc (e.g. when condition developed, severity, effects and treatment / medication). Please also include any relevant clinical letters. FORMTEXT ?????Gastro-intestinalHave you previously or are you currently suffering from any of the following:YesNoa.Inflammation of the bowel including Crohns disease, ulcerative colitis, bleeding from the rectum or diarrhoea lasting more than one week? FORMCHECKBOX FORMCHECKBOX b.Jaundice, hepatitis or other liver problems? FORMCHECKBOX FORMCHECKBOX c.Are you on any special diet that requires prescription or non-prescription supplements e.g. Coeliac Disease FORMCHECKBOX FORMCHECKBOX If YES to any of the above please give details including a diagnosis, an indication of date and duration etc (e.g. when condition developed, severity, effects and treatment / medication). Please also include any relevant clinical letters. FORMTEXT ?????Back, joint and related problemsHave you previously or are you currently suffering from any of the following:YesNoa.Problems with significant or long-standing back pain or stiffness (including neck pain) or sciatica? FORMCHECKBOX FORMCHECKBOX b.Any long-term knee pain, foot pain, injury or dislocation to any joint? FORMCHECKBOX FORMCHECKBOX c.Any other cause of long-standing muscle or joint pain e.g. arthritis or gout? FORMCHECKBOX FORMCHECKBOX d.Are you receiving physiotherapy, osteopathy or seeing a chiropractor? FORMCHECKBOX FORMCHECKBOX If YES to any of the above please give details including a diagnosis, an indication of date and duration etc (e.g. when condition developed, severity, effects and treatment/ medication). Please also include any relevant clinical letters FORMTEXT ?????Mental health and related conditionsHave you previously or are you currently suffering from any of the following:YesNoa.Anxiety, depression, phobias, mental breakdown or stress related problems FORMCHECKBOX FORMCHECKBOX b.Any eating disorder e.g. anorexia or bulimia? FORMCHECKBOX FORMCHECKBOX c.Any history of self-harm? FORMCHECKBOX FORMCHECKBOX d.Substance misuse, e.g. drugs, steroids or alcohol? FORMCHECKBOX FORMCHECKBOX If you have answered yes to any of the above, please provide answers to the following:e.Any engagement with Child and Adolescent (e.g. CAMHS) or Adult mental health services? FORMCHECKBOX FORMCHECKBOX f.Have you ever had an admission to a psychiatric facility either voluntarily or under the Mental Health Act? FORMCHECKBOX FORMCHECKBOX g.Are you currently under home crisis / home treatment team because of ongoing mental health problems? FORMCHECKBOX FORMCHECKBOX h.Have you ever experienced any thoughts of self-harm or suicide FORMCHECKBOX FORMCHECKBOX I.Are you currently accessing therapy or counselling services either online, via telephone or face to face? FORMCHECKBOX FORMCHECKBOX If YES to any of the above please give details including a diagnosis, an indication of date and duration etc (e.g. when condition developed, severity, effects and treatment/ medication). Please also include any relevant clinical letters. FORMTEXT ?????Social Care YesNoa.Have you or your children ever been under any aspect of social care / social services? FORMCHECKBOX FORMCHECKBOX bAre you currently receiving help from a social worker and/or social services or accessing a Health Visitor? FORMCHECKBOX FORMCHECKBOX c.Does your child require any extra help at school in relation to health needs? FORMCHECKBOX FORMCHECKBOX If YES, please detail below: FORMTEXT ?????????Kidney, bladder and related conditionsHave you previously or are you currently suffering from any of the following:YesNoa.Kidney stones? FORMCHECKBOX FORMCHECKBOX b.Recurrent kidney or urinary infections? FORMCHECKBOX FORMCHECKBOX c.Blood in your urine? FORMCHECKBOX FORMCHECKBOX d.Any disorders of the reproductive organs eg testicular, ovarian or any breast disease? FORMCHECKBOX FORMCHECKBOX If YES to any of the above please give details including a diagnosis, an indication of date and duration etc (e.g. when condition developed, severity, effects and treatment / medication): Please also include any relevant clinical letters FORMTEXT ?????ObstetricPlease note these questions are asked to assess supportability at your assigned location. In some countries the antenatal care may fall below UK standard and you and your baby's health may be put at risk.Females onlyYesNoa.Are you pregnant? (If yes please enter estimated due date below) FORMCHECKBOX FORMCHECKBOX If YES, please state if this is a multiple pregnancy e.g. twins, the due date, any scans, any investigations performed including the dates, and any previous pregnancy/childbirth complications: Please also include any relevant clinical letters FORMTEXT ?????b.Are you or your partner currently undergoing or considering assisted conception (e.g. IVF, IUI) FORMCHECKBOX FORMCHECKBOX If YES, please detail here: FORMTEXT ?????c.Are you planning a pregnancy? FORMCHECKBOX FORMCHECKBOX d. Do you have any other significant gynaecological / breast disease? FORMCHECKBOX FORMCHECKBOX If YES to any of the above please give details including a diagnosis, an indication of date and duration etc (e.g. when condition developed, severity, effects and treatment / medication): Please also include any relevant clinical letters FORMTEXT ?????Functional QuestionsDo you have any problems with the following?YesNoa.Mobility? e.g. walking, using stairs, balance. FORMCHECKBOX FORMCHECKBOX b.Agility? e.g. bending, reaching up, kneeling. FORMCHECKBOX FORMCHECKBOX c.Dexterity? e.g. getting dressed, writing, using tools. FORMCHECKBOX FORMCHECKBOX d.Physical Exertion? e.g. lifting, carrying, running. FORMCHECKBOX FORMCHECKBOX munication? e.g. speech, hearing. FORMCHECKBOX FORMCHECKBOX f.Vision? e.g. visual impairment, colour blindness, tunnel vision. FORMCHECKBOX FORMCHECKBOX If YES to any of the above, please give full details (e.g. extent of impairment, how you manage, or support these needs, housing modifications, occupational therapy or physio): FORMTEXT ?????Further general questionsYesNoa.Do you suffer from any blood disorder such as anaemia, sickle cell or bleeding disorder? FORMCHECKBOX FORMCHECKBOX b.Do you suffer from skin disorders such as psoriasis, eczema or other skin disease? FORMCHECKBOX FORMCHECKBOX c.Do suffer from ADHD, dyspraxia, autism? FORMCHECKBOX FORMCHECKBOX d.Have you ever been diagnosed or investigated for any cancers? FORMCHECKBOX FORMCHECKBOX e.Have you ever suffered from heat illness? FORMCHECKBOX FORMCHECKBOX f.Have you ever suffered from cold injury, had tingling or numbness, chilblains or whiteness of fingers in the cold eg Raynauds disease? FORMCHECKBOX FORMCHECKBOX g.Have you ever left a job or had to be medically retired due to ill health? FORMCHECKBOX FORMCHECKBOX h.Are you in receipt of a medical pension or disability benefit? FORMCHECKBOX FORMCHECKBOX i.Have you had to stop driving due to a medical condition? FORMCHECKBOX FORMCHECKBOX j.Are you considering gender reassignment? FORMCHECKBOX FORMCHECKBOX k.Have you sought medical attention for anything not detailed elsewhere on this form? FORMCHECKBOX FORMCHECKBOX If YES to any of the above please give details including a diagnosis, an indication of date and duration etc (e.g. when condition developed, severity, effects and treatment / medication): Please include any relevant clinical letters. FORMTEXT ?????NHS ScreeningPlease answer the following if applicable:a.Please provide the date of your most recent cervical smear. FORMTEXT ?????b.Please provide the result and any follow up details including date of next cervical smear. FORMTEXT ?????c.Please state the date of your most recent mammogram. FORMTEXT ?????dPlease provide the result and any follow up including the date of your next mammogram. FORMTEXT ?????e.Please state the date of your most recent bowel screening (FIT test or colonoscopy) FORMTEXT ?????f.Please state the result and give details of any follow up including date of next bowel screen. FORMTEXT ?????g.Vision? e.g. visual impairment, colour blindness, tunnel vision. FORMTEXT ?????Ongoing Hospital / Specialist / Consultant CareYesNoAre you on a waiting list for a hospital appointment / treatment or do you see a specialist including as an outpatient? FORMCHECKBOX FORMCHECKBOX If YES, please detail below: FORMTEXT ?????VaccinationsYesNoChild Under 18 only: Please confirm that you are fully vaccinated according to the UK immunisation schedule FORMCHECKBOX FORMCHECKBOX We require vaccination details for all under 18s prior to medical screening being completed. Please provide a copy of your vaccination details (obtained from your GP) or a copy of the vaccination pages from your NHS Red BookMedication – A copy of your repeat prescription can be attached as a substitute.Name of medicationDoseFormulationOverseas Pharmacist onlyAvailability in countryName of drug overseasShared care agreement requiredParacetamol500mg twice a dayTablets??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????AllergiesYesNoAre you allergic to anything?Please give details below including treatment e.g. Epipen: FORMTEXT ?????SECTION C – Declaration.By signing the declaration below, you are confirming that you have given all details regarding your (or your child’s) health. If it is subsequently discovered that not all medical information has been divulged, then you may be liable for any medical costs incurred. Service Personnel may be returned to the UK mainland should they or their family be deemed not to be medically supportable in an assignment location outside of the UK.By submitting this completed medical supportability assessment I confirm that the information given is accurate and that no relevant information has been withheld. I confirm that I understand the purpose of this assessment and the reasons for thecollection of my personal data, including sensitive personal data. I agree to my personal data being used to ascertain whether my medical needs can be supported outside of the UK mainland.I understand that my information will be treated confidentially yet shared with other healthcare professionals if certain aspects of clinical conditions need to be discussed. Such discussions will be treated under ‘medical in confidence’ terms. I am aware that knowingly giving false information or a failure to disclose relevant information could put mine or my child’s health at risk. This may result in my family being returned to the UK and I may be responsible for the costs of such return. I confirm that I consent to the assessing officer contacting my (or my child’s) GP to gain additional detail’s if necessary. I also consent to the access my DMICP record (electronic military health record) if I have one for visibility on previous medical history. I am aware that healthcare around the world is different to that available in the UK. I understand that I may be directed to return to the UK if it is deemed by the MOD that I cannot access the appropriate healthcare (both in terms of standards of care and required expenditure) for my requirements within the country of assignment. I have considered the impact of differing levels of healthcare within the proposed area of assignment. I have read the appropriate direction on what is available in location and confirm that I have contacted the assigning organisation to clarify any remaining questions that I may have.I confirm that I understand this self-declaration of medical conditions will be stored on a secure electronic MOD health care record system.? The outcome of the assessment made by the health professional will be passed to line management, but medical details will remain confidential.? As a medical record I acknowledge that I can have access in accordance with extant legislation.Print Name FORMTEXT ?????Signature FORMTEXT ?????(signed electronically)Date (dd/mm/yyyy) FORMTEXT ?????Name of Signatory(If completing form on behalf of a child under 18) FORMTEXT ?????Relationship to Child FORMTEXT ?????Guidance Notes: Section A, B and C should be completed electronically and returned by email as detailed below. Only one copy of section A is needed per family.Section B and C should be completed for each individual family member.Submit as individual word documents attached to a single pleted forms marked ‘Medical – In Confidence’ should be sent to: SGDPHC-O-GMSC-GroupMailbox@.uk Further information regarding this form can be gained from: SGDPHC-O-GMSC-GroupMailbox@.uk Should you wish to appeal the decision of the GMSC please contact them directly on: SGDPHC-O-GMSC-GroupMailbox@.uk within 10 working days of receiving notification.Data Protection Statement: Surgeon Generals Department along with the wider MoD, have implemented the required changes to comply with the Data Protection Act 2018/General Data Protection Regulation. In accordance with the legislation we have entered our processing activities on the MoD Article 30 Register, conducted Data Protection Impact Assessment (DPIA), updated our Privacy Policies and the other requirements as required. If you have any questions, please contact your local Data Protection Advisor or alternatively email ?SG-DPA@.uk*** PLEASE RETURN COMPLETED QUESTIONAIRES FOR ALL DEPENDANT FAMILY MEMBERS TOGETHER IN ONE EMAIL ATTACHED AS INDIVIDUAL WORD DOCUMENTS*** ................
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