Full Name *		Sex	Male Female Other
DOB *		Age *
Phone *		Email *
Address
GP Surgery		Consent to share info with GP if required	Yes No

Clinician has checked correct details*	Yes No
Consent to storage of health information	Yes No

*Good practice to check that contact details are correct and current.

Client is able to consent *	Yes No
Client is accompanied by someone able to consent on their behalf*	Yes No N/A

*(Mother, father or other adult with parental responsibility, legal guardian or person with lasting power of attorney).

Details of person consenting on behalf of another
Name		Relationship / legal status
Address

The client is happy to go ahead with the consultation and treatment. The clinician will explain the recommended treatment, including relevant benefits, potential side effects, and appropriate measures for managing any adverse reactions. *

Yes No

Use this information with the PGD document to decide if treatment can be supplied / administered. Refer to the GP/specialist if needed. Note that some of this information will not necessarily exclude treatment, but will provide a better understanding of the patient. It may influence advice provided during the consultation.

Is client fit and well today?	Yes No
Does the client have any allergies?	Yes No
Is the client pregnant or breastfeeding?	Yes No
Does the client have any of the following:
blood or clotting disorders	Yes No
kidney or liver problems	Yes No
heart or lung problems	Yes No
diabetes	Yes No
epilepsy or neurological condition	Yes No
mental health condition (depression, anxiety, other)	Yes No
disability or mobility problems	Yes No
other condition requiring regular treatment from GP or specialist	Yes No
If the patient is attending for an injection or vaccination:
Does the client have any allergies, particularly to eggs or chicken protein?	Yes No
Has the client ever had a reaction to any vaccination or a history of fainting?	Yes No