Youth Triage Form Age 13-17

"*" indicates required fields

Please complete this questionnaire if you wish your symptoms be assessed by your GP Surgery. This service is only provided on Monday to Friday, 8.30am to 6.30pm. To find out more about your symptoms or condition, please visit www.nhs.uk/Conditions

Full Name*

Date of Birth*

Contact Number*

Consent to SMS?*

Yes

This form is being completed by*

Parent/Guardian

Please describe your current symptoms or problem*

When did your symptoms start? Optional

Does anything make your symptoms better? Optional

Does anything make your symptoms worse? Optional

Do you have any other symptoms that you are concerned about? Optional

Have you seen anyone previously about this? If yes, who? Optional

What treatments have you tried already? Optional

Do you have any ideas what might be causing your symptoms? Optional

What would you like to happen as a result of this assessment? e.g. appointment, prescription or referral? Optional

Please let us know the phone number or email address you would like us to reply to you on.*

When you are happy with your answers, click 'Submit' below to send the questionnaire to your GP Practice. Your GP Practice will then assess your answers and will contact you with the appropriate follow-up advice. If you have not heard anything after 48 hours, please phone your GP Practice directly.

Phone Optional

This field is for validation purposes and should be left unchanged.

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