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Medical Assessment Form
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Medical Assessment Form
* Full Name:
I am completing the form myself I am completing the form on behalf of someone else. Please write your full name, relationship and contact number below
* Age:
* Date Of Birth: Calandar
* Place Of Birth
How would you describe you general health?
  Poor     Good Excellent Not Sure  
Main reason for consultation:
Other concerns:
Please select nearest title relating to your condition or symptoms:  [Tick appropriate concern]
  Blood   Breast Breast Surgery  
General/Specific test
Infection /Discharge
  Cardiovascular Counselling Gastrointestinal  
Chest Pain/Angina
Pre /Post Surgery
Difficulty swallowing
Difficulty Breathing
Post STI diagnosis
Painful Abdomen
Palpitation/ fainting
Well Assessment/Other
Weight Loss /Exercise
Gastric reflux/Indigestion
  Ears/Nose/Throat Eyes    
Blurred vision
Swollen /Red
  Genitourinary Musculoskeletal Neurological  
Back Pain/Injury
Sleep Disorder
Industrial Injury
Other complaints
Sports related Injury
Physical disability Cosmetology
Specific Counselling
  Psychological Psychosexual Sexual and Reproductive Health  
Stress / Trauma
Body Image Issues
Wellness Check
Anxiety Disorder
Growing Pains
Contraceptive advice
Personality Issues
Post Op Issues
STI/STD screening
Loss of Libido
Partner Notification Service
Counselling - Specific
Sex and Physical
Pre / Post TOP Support
Child Development
Sex and Relationship
Female Menopause
Child Sexual Abuse
Male Menopause
Adult survivors Sexual Abuse
STI / STD treatment
Psychometric test
Non-STI/STD Genital Complaints 
  Skin/Dermatological   Occupational Health assessment Vaccination  
Allergies / Rashes / Hive
Fitness for work checks
Childhood Vac
Hyper Pigmentation
Pre employment tests
Travel Vac/Cert
Office based Medical Assessment
Nursing and General Community Care Service Administrative Services
Home help – shopping/collection/escort
Passport Signing
Medical Escorts local /national/international
Medical or Travel Certificate
Home Assistance
Medical Statements/letter
General Nursing / Midwifery service
Sick Certificate
Elderly Nursing Care – Home
Please describe your health problems in the box below:
I feel unwell because:
I have / not received treatment at ... before for this condition cross off as applicable
I need help with...
General Practitioner -  Doctor
GP Details Name:
Full address incl. Post Code:
Telephone No:
Fax No:
Psychologist / Therapist / Counsellor / Alternative practitioner / Midwife/Nurse/Carer / Other
Full Name: (Include title)
Full address incl. Post Code:
Telephone No:
Fax No:
Personal Details
*Your Name:
*Full address incl. Post Code:
Mobile No:
Landline No:
*Email address:
Next of Kin:
Name and Contact details:
Telephone No/S:
Medical History including Allergies
Previous Medical History:
Previous Surgery:
Previous health problems:
Past /ongoing management if applicable:
Other special circumstances or  relevant information


Patient Declaration

I understand that in order for RSP Healthcare Consortium to arrange the right services and or practitioner.

That the information I provide in the self-assessment may be shared with other professionals who may be involved in helping meet my needs.  

By continuing with self-assessment, I give consent to my information being shared for these purposes.


If I am completing an assessment form on behalf of someone else by continuing with the assessment, I confirm that they are aware that:

I am doing this on their behalf and

I have informed them that information about them may be shared with other professionals in order to help meet their needs.


RSP Healthcare Consortium cannot guarantee that a particular service selected will be available. If the service you have selected is not available, alternative support will be provided. We strongly recommend that you read the questions at the top of this page before starting your self-assessment.


Medical Self-assessment

Medical Self-assessment can save you time and money.

It also gives people the choice to assess their own health and needs or carry out an assessment on behalf of someone else prior to consultation.


Who can complete medical assessment form?

A self-assessment can be completed by anyone aged 18 or over. 

Children and others needing assistance should seek help from parents or responsible adults.

Carers, friends or family can complete the self-assessment on behalf of someone else.  This person helping must be aged 18.

In this case, we will always contact the person concerned to check that they are in agreement.



Giving you the time, choice and providing a faster response

After you complete a self-assessment you will receive an instant response informing if you, or the person you are completing the assessment for, are eligible for services.  

A further assessment will be made for specific conditions and people who have more complex needs than we cover in the self-assessment.  This will involve meeting the person who is being assessed to give them the opportunity to discuss their needs and wishes and a physical examination may be required.   If your initial assessment is via telemedicine (video consultation) or audio concultation, you may have to have physical tests and blood works.

We always encourage relatives or carers to be involved in this discussion, and to provide support during examination with your permission.

A further consultation with the nurse, counsellors, or therapists does not always involve a physical medical examination.

We would only speak to a person's doctor if they have given us permission.  You may choose to discuss any proposed examinations, treatment and or care package further with practitioners before proceeding with treatment or services.  We would always try to help you resolve your complaints.  If we agree to provide your treatment | personal service | family care service package etc, you will be promptly notified and offered an appointment for consultation and to scheduled a suitable care package to suit your personal or family circumstances. 


Choose and Book and Service Payment

Choose and Books allows you to choose care needed and make payment for consultation and all treatments instantly using preferred payment method.

Online payment via PayPal and bank transfers through the BACS systems are accepted, as we the cheque and cash payment methods, but you will need to wait for the payment clearance before consultation for treatment commences.


RSP Health Reward and Gift Vouchers

RSP Health voucher can be purchased in advance online, for yourself or for loved ones as health gifts, job incentive or promotional awards. RSP Health Vouchers can be redeemed against payment for all services, medical or therapy charges.


Please send your booking payment enquiries to or call 08455760031 to confirm payment.

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