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Eve Hill Medical Practice NHS GP Surgery in Dudley

Extra support required for cervical screening

Your support needs

Some experiences or conditions may affect how comfortable you feel during appointments. Please select any boxes that apply to you

I have a mental health condition

My mental health causes physical symptoms (e.g., shaking)

I find it hard to leave my house

I sometimes find it difficult to process information

I do not like feeling exposed or undressed

I feel embarrassed about my body

I have scars

I feel judged

I feel like a burden

I am afraid the examination may hurt

I may cry or freeze during an appointment

I may pass out or faint

I may have a panic attack

I become distressed during physical examinations

I have had a difficult or traumatic smear test experience

I have experienced trauma

I am a survivor of sexual violence

I am a survivor of female genital mutilation/cutting (FGM/C)

I would like to be warned before the nurse touches me

Waiting rooms make my symptoms worse

Are there any words or phrases that may trigger distress or flashbacks?

Are there other concerns or things you would like us to know?

Do you have any suggestions for how we could help you feel more comfortable or supported during your appointment?

Once we receive this form, a member of the nursing team will contact you to discuss your needs further. Are you happy for us to contact you? *

Yes

If you are human, leave this field blank.

29 Himley Road
Dudley
West Midlands
DY1 2QD

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01384 254423

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