Medical History Questionnaire

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Medical History Form

Confidentiality and consent

Dementech Neurosciences collects and stores large amounts of personal data every day, such as medical records.

We take our duty to protect your personal information and confidentiality very seriously and are committed to taking all reasonable and required measures to ensure the confidentiality and security of personal data for which we are responsible, whether computerised or on paper.

At Dementech Neurosciences, we have appointed a Registered Manager who is accountable for the management of all Information assets and any associated risks and incidents, and acts as a Caldicott Guardian who is responsible for the management of patient information and patient confidentiality.

The healthcare professionals caring for you keep records about your health and any care you receive from them at Dementech in order to ensure that the highest standard of care is delivered. These records may include

  • Basic details about you such as name, address, date of birth, next of kin, etc.
  • Contact we have had with you such as appointments or visits and/or notes about your health, treatment and care
  • Test/Exam results
  • Relevant information from people who care for you, look after you and know you well, such as health professionals and/or

It is essential that your details are accurate and up to date. Always check that your personal details are correct when you visit us and please inform us of any changes as soon as possible.

Your records are used to direct, manage and deliver the care you receive and ensure that:

  • The healthcare professionals involved in your care have accurate and up to date information to assess your health and decide on the most appropriate care/treatments for you
  • Healthcare professionals have the information they need to assess and improve the quality and type of care you receive
  • Your concerns can be properly investigated if a complaint is raised
  • Appropriate information is available if you see another doctor or are referred to another specialist at Dementech

Your information may also be used to help us improve Dementech’s services by:

  • Reviewing the care we provide to ensure it is of the highest standard and quality
  • Ensuring our services can meet patient’s needs in the future
  • Investigating patient queries, complaints and/or legal claims
  • Preparing data/statistics on Dementech’s performance Audit, Dementech’s accounts and services
  • Undertaking research and development (with your consent and you may choose whether or not to be involved)
  • Helping to train and educate healthcare professionals (with your consent and you may choose whether or not to be involved).

Everyone working within Dementech Neurosciences has a legal duty to keep information about you confidential. Similarly, anyone who receives information from us has a legal duty to keep it confidential. We will share information with the following main organisation:

  • Other NHS and private organizations and hospitals involved in your care (Alliance Medical, The Wellington Hospital and others. For full list of our collaborators, please get in touch with us on 020 3848 4500)
  • Clinical Commissioning Groups (CCGs), Strategic Health Authorities and other NHS bodies such as Ambulance Services
  • General Practitioners

You may be receiving care from other people, for example social services, who we might need to share your information with so we can work together for your benefit – if they have a genuine need for it and only after we have your permission.

We will not disclose your information to any other third parties without your permission unless there are exceptional circumstances, such as if the health and safety of others is at risk or if the law requires us to pass on inform.

Disclosure of information

You have the right to restrict how and with whom we share the personal information from your records. This must be noted explicitly within your records so all healthcare professionals and staff treating you are aware of your decision. Disclosure of your information is always done through encrypted means of communication and in accordance with GDPR guidelines.

By choosing this option, it may make the provision of treatment or care more difficult or unavailable. You can also change your mind at any time about a disclosure decision.

How you can access your health records:

  • The Data Protection Act 1998 gives you a right to access the information we hold about you on our records.
  • Your request must be in writing by completing a Subject Access Request form and sending it to the clinic’s Information Governance Manager
  • There will be a charge to have a printed copy of the information held about you, which is in accordance with the Data Protection Act. This fee includes the time taken to locate the record and the printing costs involved.
  • For copies of records requested by patients/patient’s representatives: £30
  • For copies of records requested by Solicitors: £50

We are required to respond to you within 30 working days

You will need to provide adequate information (i.e. full name, address, date of birth, etc) so that your identity can be verified and your records