How are you?

First Name

Last Name

Date of Birth

Email

Class

Dr’s & Medication(s) - In the last 3 months:

In the last 3 months, how many times have you been in contact with your GP/Medical Practice/Consultant?

How many different medications have you been taking? (Please just give number of medications, not list all names)

Have you been taking medication(s) every day?

Yes

No

Are any of your regular medications opiates?

Yes

No

As you answered yes, please write down their name(s), dosage and how often you take them?

Quality of sleep

Pain

Mobility

Anxiety

Depression

Ability/confidence to go out/leave your home?

Ability to walk

Ability to work/volunteer

Ability to do things at home

See friends/family socially

Do things you enjoy e.g. read a book, cook, garden, art/crafts etc.

Do you feel you are in need of any aids within the home?

Yes

No

Please score between 1-10