Self-Referrals

Units:

Pint of regular beer/cider/lager - 2 units
Alcopop or can of beer/lager/cider - 1.5 units
Glass of wine (175ml) - 2 units
Single measure of spirts - 1 unit
Bottle of wine - 9 units

If your score (table 1 and 2 combined) is 5 points or more, please complete the Extended Alcohol questionnaire below.

Units:

Pint of regular beer/cider/lager - 2 units
Alcopop or can of beer/lager/cider - 1.5 units
Glass of wine (175ml) - 2 units
Single measure of spirts - 1 unit
Bottle of wine - 9 units

If your score above is 5 points or more, please complete the Extended Alcohol questionnaire below (tables 3 and 4).

To help the staff involved in your care make better and safer decisions about how best to treat you.

You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care.

Your options are outlined below; please indicate your choice on the form below.

a) Express consent for medication, allergies and adverse reactions only. You wish to share information about medication, allergies and adverse reactions only.

b) Express consent for medication, allergies, adverse reactions and additional information.
You wish to share information about medication, allergies and adverse reactions and further medical information that includes: Your significant illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you.

c) Express dissent for Summary Care Record (opt out). Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care.

Please note that it is not compulsory for you to complete this consent form. If you choose not to complete this form, a Summary Care Record containing information about your medication, allergies and adverse reactions and additional further medical information will be created for you as described in point b) above.

The sharing of this additional information during the pandemic period will assist healthcare professionals involved in your direct care and has been directed via the Control of Patient Information (COPI) Covid-19 – Notice under Regulation 3(4) of the Health Service Control of Patient Information Regulations 2002.

You are free to change your decision at any time by informing your GP practice.

Having read the above information regarding your choices, please choose one of the options below.