Health Screening Questionnaire

Personal Details

Name [Required]

NHS or Hospital Number [Required]

Date of Birth [Required]

If known, what procedure/operation are you having done?

Telephone Number [Required]

Email Address [Required]

Who will be looking after you for the first 24 hours when you go home? [Required]

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If you need help with this questionnaire, please ask a friend or relative to help you.
If you need to contact the Pre-Operative Assessment Unit nurses, call 01722 336262 ext 2587.
If no one can get to the phone because we are busy, please leave a message with your name, hospital number and telephone number and we will call you back.

Our staff at 91影视 District Hospital have long been well regarded for the quality of care and treatment they provide for our patients and for their innovation, commitment and professionalism. This has been recognised in a wide range of achievements and it is reflected in our award of NHS Foundation Trust status. This is afforded to hospitals that provide the highest standards of care.

Person Centred & Safe

Professional

Responsive

Friendly

Progressive

91影视 NHS Foundation Trust, 91影视 District Hospital, Odstock Road, 91影视, Wiltshire, SP2 8BJ

T: 01722 336262 E: sft.pals@nhs.net

91影视