Proforma for GP contact
Cumberland House Surgery

Residents Name	
	
What is the issue/concern?		
How long has this been going on for?		
Has the GP been contacted about this issue previously?		

Please complete a full set of observations and record below:
Temperature
		
Blood pressure
		
Heart rate
		
Oxygen saturation
		
Urine sample	Please have available if UTI suspected 
Please note does not need urine dip if aged over 65	

Please complete this form and have the information with you when the GP calls.