Adult with Learning Disabilities Health Check

People with a learning disability often have poorer physical and mental health than other people. This does not need to be the case.

It is important that everyone over the age of 14 who is on their doctor’s learning disability register has an annual health check.

An annual health check can help you stay well by talking to a doctor or nurse about your health and finding any problems early, so they can be sorted out.

You do not have to be ill to have a health check – in fact, most people have their annual health check when they are feeling well.

If you are worried about seeing a doctor, or there is anything they can do to make your appointment better, let the doctor or nurse know.

They can make changes to help you. These are called reasonable adjustments.

For further information please click here

First Name *

Last Name *

Email *

Enter Email

Date of birth

Please use format day/month/year e.g. 12/05/1979

Phone Number *

The questions below should be answered either by the patient or their carer if required.

Does the Patient live in supported accomodation?

Patients next of kin or name of key support worker who can speak on their behalf and their contact details.

Is the patient non-verbal?

Yes

Does the patient have epilepsy?

Yes

Does the patient have mental health problems?

If so please give as much detail as possible.

Does the patient have a physical disabilty? E.g are they able to walk, wash and dress themselves?

If so please give as much detail as possible.

Has the patient contacted Out of hours GP service within the last 12 months?

Yes

If so how many times ?

Has the patient attended Accident and Emergency in the last 12 months?

Yes

If so how many times ?

If the patient has a carer on whom they are dependent and the carer were to become unwell how would this impact on the patient?

Does the patient have a default back up carer? if so please provide details.

Once the electronic review has been reviewed by a clinician the patient may be invited for a general health check with the HCA, please confirm the most appropriate contact details to arrange this

If so please give as much detail as possible.

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This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

I consent to the practice sharing my key information summary with secondary care.

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