Local working patient

Date of birthGenderPreferred name PhoneEmailPostcode Address GP surgeryGP phone Arrival time Referral time

Method of arrival

Ambulance Police Self Other

Initial Greet timeCompleted bySelect an HCAOther

Ethnicity

White British Another ethnicity Not stated/unknown

Next of kin nameNext of kin phoneNext of kin address

Consent to share with next of kin

Yes No

Children under 18

Add another

Add a name and date of birth where applicable.

Medication with person

Yes No

Allergies

Yes No

Other services

Yes No

Recent drug / alcohol use

Yes No

Veteran / dependent

Yes No Not known

Physical descriptionGeneral presentation

Accompanied?

Yes No

Initial Greet details

Fit for assessment

Yes No