<!-- BEGIN worklist/local/outreach/questionnaire.tt -->
<div class="questionnaire">
<h4>PATIENT QUESTIONNAIRE</h4>
<p class="strong">
Please complete this form and return it with the blood samples to:<br />
[% c.cfg('settings').lab_name_abbreviation %],
[% c.cfg('settings').service_address %]
</p>
<p class="strong">
Contact Andy Rawstron or Carol Reid on [% c.cfg('settings').service_telno %]
</p>
<div class="patient_details">
<p class="title">Patient details (please amend if necessary)</p>
<p>Name: [% entry.first_name | ucfirst %] [% entry.last_name | upper %]
<span class="indent">D.o.B: [% entry.dob.strftime('%d.%b.%Y') %]</span>
</p>
<p>Address: [% entry.address %]</p>
<!-- <p id="narrow"> </p> // to allow space to amend address -->
<p>Tel No:
[% IF entry.contact_number; entry.contact_number; ELSE %]
<input type="text" class="tel_no" />
<span class="tel_no">« please tell us your telephone number so we
can contact you if necessary. We will not share it with anyone else.
</span>
[% END %]
</p>
<p>GP: [% entry.practitioner | html %], [% entry.practice_address | html %]</p>
</div>
<table>
<tr>
<td>
<p class="expanded">Have you been to hospital in the last six months?<br />
If yes, give details:
</p>
</td>
<td align="right" valign="top">
Yes <input type="text" />
No <input type="text" />
</td>
</tr>
</table>
<table>
<tr>
<td>
<p class="expanded">Have you started any new medications in the last six months?<br />
If yes, give details:</p>
</td>
<td align="right" valign="top">
Yes <input type="text" />
No <input type="text" />
</td>
</tr>
</table>
<table>
<tr>
<td>
<p class="expanded">Have you had any infections in the last six months?<br />
If yes, give details:
</p>
</td>
<td align="right" valign="top">
Yes <input type="text" />
No <input type="text" />
</td>
</tr>
</table>
<table>
<tr>
<td>What is your current weight?</td>
<td align="center">
<input class="data" type="text" /> kg -OR-
<input class="data" type="text" /> stones
<input class="data" type="text" /> pounds
</td>
</tr>
</table>
<table>
<tr>
<th colspan="5" class="border">Do you currently have any of the following symptoms:</th>
<th colspan="2">If so, is it:</th>
</tr>
<tr>
<td align="center"> </td>
<td align="center">No</td>
<td align="center">Sometimes</td>
<td align="center">Often</td>
<td align="center" class="border">Often &<br />drenching</td>
<td align="center">New</td>
<td align="center">Long-<br />standing</td>
</tr>
<tr>
<td align="center">Night sweats:</td>
<td align="center"><input type="text" /></td>
<td align="center"><input type="text" /></td>
<td align="center"><input type="text" /></td>
<td align="center" class="border"><input type="text" /></td>
<td align="center"><input type="text" /></td>
<td align="center"><input type="text" /></td>
</tr>
<tr>
<td colspan="7"><hr noshade="noshade" /></td>
</tr>
<tr>
<th colspan="7">Bone pain (<u>not</u> arthritic or muscular pain):</th>
</tr>
<tr>
<td align="center"> </td>
<td align="center">No</td>
<td align="center">Mild</td>
<td align="center">Moderate</td>
<td align="center" class="border">Severe</td>
<td align="center"> </td>
<td align="center"> </td>
</tr>
<tr>
<td align="center"><span class="indent">Ribs</span></td>
<td align="center"><input type="text" /></td>
<td align="center"><input type="text" /></td>
<td align="center"><input type="text" /></td>
<td align="center" class="border"><input type="text" /></td>
<td align="center"><input type="text" /></td>
<td align="center"><input type="text" /></td>
</tr>
<tr>
<td align="center"><span class="indent">Back</span></td>
<td align="center"><input type="text" /></td>
<td align="center"><input type="text" /></td>
<td align="center"><input type="text" /></td>
<td align="center" class="border"><input type="text" /></td>
<td align="center"><input type="text" /></td>
<td align="center"><input type="text" /></td>
</tr>
<tr>
<td align="center"><span class="indent">Upper arms</span></td>
<td align="center"><input type="text" /></td>
<td align="center"><input type="text" /></td>
<td align="center"><input type="text" /></td>
<td align="center" class="border"><input type="text" /></td>
<td align="center"><input type="text" /></td>
<td align="center"><input type="text" /></td>
</tr>
<tr>
<td align="center"><span class="indent">Upper legs</span></td>
<td align="center"><input type="text" /></td>
<td align="center"><input type="text" /></td>
<td align="center"><input type="text" /></td>
<td align="center" class="border"><input type="text" /></td>
<td align="center"><input type="text" /></td>
<td align="center"><input type="text" /></td>
</tr>
<tr>
<td colspan="7"><hr noshade="noshade" /></td>
</tr>
<tr>
<td align="center" rowspan="2">Unexplained<br />swelling:</td>
<td colspan="4" rowspan="2">
<table class="borderless">
<tr>
<td align="center">No</td>
<td align="center">Neck</td>
<td align="center">Armpits</td>
<td align="center">Abdomen</td>
<td align="center" class="border">Groin</td>
</tr>
<tr>
<td align="center"><input type="text" /></td>
<td align="center"><input type="text" /></td>
<td align="center"><input type="text" /></td>
<td align="center"><input type="text" /></td>
<td align="center" class="border"><input type="text" /></td>
</tr>
</table>
</td>
<td align="center"> </td>
<td align="center"> </td>
</tr>
<tr>
<td align="center"><input type="text" /></td>
<td align="center"><input type="text" /></td>
</tr>
</table>
<p> </p>
<p class="break">
<b>Please give details of any symptoms that you have, or any
other comments you would like to make on the other side of this page.
Thank you for your help.
</b>
</p>
</div>
<!-- END worklist/local/outreach/questionnaire.tt -->