Embarrassing Bodies : Live From the Clinic Application Form Thank you for showing an interest in “Embarrassing Bodies : Live From the Clinic”. This groundbreaking live series is an opportunity for patients who are concerned about a condition and who are selected to take part in the programme, to take action and see a doctor `out of hours’. Skyping in from home is already being introduced in some surgeries around the UK and if you are selected, this programme provides an opportunity to get advice and learn more about your medical condition. Using cutting-edge technology, such as Skype, webcams and twitter, the series will feature a team of doctors, including Channel 4’s own Christian Jessen, Dawn Harper and Pixie McKenna, alongside a variety of specialist consultants, who will provide patients with on-the-spot consultations, advice on the options available and how to make the most of their own GP and local medical services. We will also be conducting live, interactive health checks, with specialists advising how to check yourself at home, demonstrated by volunteers live in the studio. If you would like the chance to speak to our doctors in an on-screen consultation, via webcam from the comfort of your own home and broadcast live on Channel 4, please complete the form below. The information collected on this application will be kept in the strictest confidence and will not be disclosed to any third party (except the Broadcaster) for any purpose other than for the purposes stated herein. Your personal information will only be used for the purpose of evaluating whether you would be a suitable contributor to the programme or any other programme produced by Maverick Television Ltd. Your personal information will NOT be used for any marketing, publicity or research purposes. By completing this form you agree for your personal and sensitive information to be processed lawfully by Maverick for the purposes of the proposed programme. All information will be dealt with according to the Data Protection Act 1998 and all other applicable laws and regulation with respect to Data Protection. Please note that while we will enlist the help of reputable professionals in their fields, we cannot of course guarantee that if you are ultimately selected that our medical team will be able to solve your medical problems, successfully treat your conditions or that you will be completely happy with any of the treatments that you receive.
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GUIDANCE FOR APPLICANTS • If you are concerned about your symptoms, you should see your own GP immediately. Any live, on air consultations will not take place until April and May 2014. Whether you get selected or not, you should also ensure you see your own GP or dentist. • Our consultations are advice only, we are rarely able to offer treatment • Your application is confidential - your application will only be viewed by production staff and the medical team and where necessary Channel 4 personnel for the purpose of broadcast. • Under 18 applications – you will need parental consent to take part in the programme. Please fill in the relevant box below with your parent/guardian’s contact details. • All Applicants – Please enclose/attach (a) A head and shoulders photograph, (b) Coloured photographs of your health concern/symptoms • Please note that any photographs of your symptoms included in your application may be used on television during the programme to assist the doctor with your appointment. This footage may subsequently feature on the programme’s website. • Please ensure you complete all of the required fields below, including the health questionnaire. The more you tell us in advance, the more we may be able to help you. • Please note, we cannot guarantee that you will receive a consultation. • Before completing your form, please consider whether you will be able to commit to a consultation. • You can email or post your application to us. Details can be found at the end of the application form.
PERSONAL DETAILS
NAME AGE
Alicja 29
MALE FEMALE (Please tick) DATE OF APPLICATION WEIGHT
DATE OF BIRTH
09-08-1985
HEIGHT
167
EMAIL ADDRESS
[email protected]
CONTACT NUMBERS
MOBILE 07735519651 WORK
*Please also tick the number you’d prefer to be contacted on HOME ADDRESS
07-08-2014 48
HOME 176 Beacon Road Chatham ME5 7BX Kent
PLEASE TELL US WHEN IS THE BEST TIME TO GET HOLD OF YOU OVER TELEPHONE? Any time :)
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OCCUPATION
part time factry worker
(Please state if you are full time or part time) PREVIOUS TV EXPERIENCE (if any) GP – NAME AND ADDRESS (if known)
West drive surgery chatham End Road
UNDER 18’S – PLEASE COMPLETE DO YOUR PARENTS KNOW ABOUT YOUR CONDITION?
Y/N
HAVE YOUR PARENTS GIVEN YOU CONSENT TO CONTACT US?
Y/N
PARENT/GUARDIAN’S CONTACT DETAILS
YOUR HEALTH COMPLAINT DESCRIBE YOUR HEALTH COMPLAINT (For person applying) over over stress because of my sytuation :(
PLEASE DESCRIBE YOUR SYMPTOMS (How does it look, feel, smell etc.) My breast is looking so bad that its damage my life i shy to be naked around my partner I think because of my breast he is not satissfaid with our sex life etc. I so stresd about this its looking very sogi and soft Ugly :( Please help me
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HOW LONG HAVE YOU HAD THE CONDITION? (When did it first start?) around 7 years after breast fiding DOES ANYONE ELSE IN YOUR FAMILY SUFFER FROM THE SAME CONDITION? no ARE YOU HAPPY TO SHOW OUR ON SCREEN DOCTORS THE CONDITIONS ON TV? Yes If NO, please explain why?
No
HAVE YOU VISITED A GP/DENTIST/SPECIALIST RELATING TO THIS CONDITION? IF YES: •
WHEN?
•
WHO DID YOU SEE? (GP / Dermatologist / Gynaecologist etc) (Please give names of doctors/hospitals where appropriate)
•
WHAT WAS THE DIAGNOSIS?
• DID YOU RECEIVE TREATMENT?
Yes
IF NO: WHY NOT? I dont have the money to change my sytuation :( IF YES: WHAT TREATMENT DID YOU RECEIVE?
IF YOU HAVEN’T SEEN ANY MEDICAL PROFESSIONALS YET, WHY NOT?
ARE YOU SUFFERING FROM ANY MENTAL HEALTH CONCERNS ? (Including depression - please detail any past or present treatments) I AM TAKING FLUOXETINE FOR DEPRESSION :(
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PLEASE DESCRIBE WHAT TREATMENTS YOU HAVE TRIED/TESTED (Please give details and dates) different creams and pills
HOW DOES THE CONDITION AFFECT YOUR LIFE? (Confidence, behaviour, home life, school life, work, relationships and friendships) its chang me completly I lost my confident I feel very down im jeluas my relationship is very very difficult I hate my self
HOW DOES IT MAKE YOU FEEL AND WHAT WORRIES YOU THE MOST? Its make me feel like Im not woman any more :(
Have you ever be in contact with or currently seeing a psychologist / psychiatrist / CPN or counsellor? Yes No If YES when?
Have you ever self-harmed? Yes
No
PLEASE LIST DATES THAT YOU MAY NOT BE AVAILABLE IN FROM APRIL 2014 (If any)
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DO YOU HAVE ANY CRIMINAL CONVICTIONS PAST OR PENDING?
Yes
No
If yes, please give details with type of All information supplied remains confidential.
ARE YOU INVOLVED IN ANY COURT PROCEEDINGS AT PRESENT OR AWAITING TRIAL OR CHARGE IN RESPECT OF ANY CRIMINAL OFFENCE OR SUSPECTED CRIMINAL OFFENCE?
conviction/proceeding, including dates.
Yes No If yes, please give details with type of conviction/proceeding, including dates.
Please include any marital/child proceedings. All information supplied remains confidential. If you have changed your name either through marriage or deed poll, please state your maiden name or any other name you have been known by
Yes
No
Do you have a webcam/camera built in to your computer?
Yes
No
I confirm that I am happy to appear on television should my application be successful.
Yes
No
Do you have access to the internet at home?
Yes
No
WOULD YOU LIKE TO BE CONSIDERED FOR OTHER MAVERICK TELEVISION SHOWS?
Please complete the Health Questionnaire below.
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‘EMBARRASSING BODIES’ – HEALTH QUESTIONNAIRE Please click in the appropriate column and where an answer is ‘yes’ please provide details. You may attach an additional sheet where necessary
DO YOU HAVE A FAMILY HISTORY OF: Heart disease? High blood pressure? Stroke? Cancer? Diabetes? Blood disorders?
No
HAVE YOU EVER SUFFERED:
Yes
NO
YES
Remarks:
REMARKS:
Angina? Heart Attack? Other heart problems? High blood pressure? Irregular heartbeat? Stroke? Ankle Swelling? Pain in legs on walking? Thrombosis (Blood Clots)? Other circulation problems? Shortness of breath? Persistent cough? Coughing up blood?
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HAVE YOU EVER SUFFERED: NO Asthma? Gall Stones Recurrent indigestion/heartburn? Stomach ulcer? Hernia? Recurrent diarrhea/constipation? Other bowel problems? Hepatitis? Other liver problems/Jaundice? Diabetes? Thyroid problems? Other glandular problems? Any tropical disease e.g. malaria? Glaucoma/other eyesight problems? Deafness/other ear/hearing problems? Bronchitis? Pneumonia? Other lung problems? Tuberculosis? Prostate Problems? Kidney stones/disease? Other urinary problems? Epilepsy? Cancer? Mental health problems such as anxiety or depression? Eating Disorders? Skin Problems? Recurrent back ache? Other back problems? Arthritis? Rheumatic fever? Other joint problems? Sciatica? Anaemia? Any other health problems please list.
YES
REMARKS:
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LIST ALL CURRENT MEDICATION LIST ANY ALLERGIES (include inhalers, injections, HRT, (include drugs/medication) contraception pills, & alternative medicines, e.g. homeopathic/herbal).
LIST ALL PREVIOUS SURGERY (include details of operations, specialist names, hospitals and dates where possible).
DO YOU SMOKE? If yes, how many per day? DO YOU HAVE, OR HAVE YOU EVER HAD, ISSUES WITH: Drugs? Alcohol?
ANY OTHER INFORMATION THAT YOU MAY WISH TO DISCLOSE AND/OR MAY BE USEFUL TO THE DOCTOR
No
Yes
Remarks:
No
Yes
Remarks:
THANK YOU FOR TAKING THE TIME TO COMPLETE THE APPLICATION FORM. PLEASE DO NOT FORGET TO ATTACH PHOTOGRAPHS WHEN YOU SEND IN YOUR APPLICATION. (taken landscape please) (Unfortunately we will not be able to return these) PLEASE POST TO: Embarrassing Bodies Maverick TV Progress Works Heath Mill Lane, Birmingham, B9 4AL TEL: 0121 224 8395 EMAIL:
[email protected]
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