Client Service Receipt Inventory – Please E-mail back to talkingtherapies@berkshire.nhs.uk

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

CentreHospital

OutpatientMy own home

Physiotherapist

GP Practice

……..

Community Centre

Hospital Outpatient

My own home

Occupational Therapist (OT)

GP Practice

……..Community

CentreHospital

OutpatientMy own home

Specialist Nurse (e.g. cardiac nurse, diabetes nurse)

GP Practice

……..Community

CentreHospital

OutpatientMy own home

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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

CentreHospital

OutpatientMy own home

Social Worker

GP Practice

……..Community

CentreHospital

OutpatientMy own home

Drug and alcohol advisor

GP Practice

……..Community

CentreHospital

OutpatientMy own home

Other counsellor/ therapist/ clinical psychologist (outside of Talking Health or Talking

Therapies)

GP Practice

……..Community

CentreHospital

OutpatientMy 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)?

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In the last 3 months have you been admitted to hospital as an inpatient? Yes No

Name of Hospital Reason for AdmissionHow 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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