Client Service Receipt Inventory Please E-Mail Back To
Client Service Receipt Inventory – Please E-mail back to
First Name(s) / Last Name(s) / Date of Birth: / Today’s Date:Have you seen any of the following healthcare professionals in the last 3 months?
(Please tick for yes; leave blank for no) / Where did you see this healthcare professional? / Number of contacts in the last 3 months / Reason for Attending
General Practitioner (GP) / GP Practice / ……..
Community Centre
Hospital Outpatient
My own home
Practice Nurse / GP Practice / ……..
Community Centre
Hospital Outpatient
My own home
Physiotherapist / GP Practice / ……..
Community Centre
Hospital Outpatient
My own home
Occupational Therapist (OT) / GP Practice / ……..
Community Centre
Hospital Outpatient
My own home
Specialist Nurse (e.g. cardiac nurse, diabetes nurse) / GP Practice / ……..
Community Centre
Hospital Outpatient
My own home
Doctor other than GP for a physical health problem (e.g. cardiologist, gastroenterologist, oncologist, etc.) / GP Practice / ……..
Community Centre
Hospital Outpatient
My own home
Podiatrist / GP Practice / ……..
Community Centre
Hospital Outpatient
My own home
Social Worker / GP Practice / ……..
Community Centre
Hospital Outpatient
My own home
Drug and alcohol advisor / GP Practice / ……..
Community Centre
Hospital Outpatient
My own home
Other counsellor/ therapist/ clinical psychologist (outside of Talking Health or Talking Therapies) / GP Practice / ……..
Community Centre
Hospital Outpatient
My own home
Home treatment team/ Crisis team member/ Assertive Outreach team member/ Community Mental Health Team Member (e.g. Psychiatrist, Mental Health Nurse, CPN) / GP Practice / ……..
Community Centre
Hospital Outpatient
My own home
In the last 3 months how many times have you attended A+E (Accident and Emergency)?
In the last 3 months have you been admitted to hospital as an inpatient? Yes / No
Name of Hospital / Reason for Admission / How many days were you in hospital for? / Do you know the date that you were admitted?
Have you needed to call an ambulance in the last 3 months Yes / No
How many times have you needed an ambulance in the last 3 months / Reason for calling the ambulance
……..
In the last 3 months have you had any of the following investigations or diagnostic tests? / Number of investigations/ tests in the last 3 months
Magnetic Resonance Imaging (MRI) / ……..
CT/ CAT Scan / ……..
Ultrasound / ……..
X-Ray / ……..
Electroencephalogram (ECG) / ……..
Blood Test / ……..
Are you in paid employment? Yes
How many days have you had off due to ill health in the last 3 months?
…….. / No
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