Do You Currently Or Have You Ever Suffered from the Following
Please complete all forms prior to registration. Information is treated in line with our confidentiality policies. All information is utilised to enhance your healthcare.
FULL NAME:DATE OF BIRTH: / MARITAL STATUS:
OVER 75
(please tick)
NHS NUMBER
PRESENT ADDRESS:
TELEPHONE NUMBER: / MOBILE NUMBER
OCCUPATION / PREVIOUS DOCTOR
PREVIOUS ADDRESS:
CURRENT MEDICAL HISTORY
Do you currently or have you ever suffered from the following:
Asthma / Chronic Obstructive Pulmonary DiseaseDiabetes / High Blood Pressure
Thyroid Problems / Epilepsy
Problems relating to your heart / Cancer
Mental Health problems
Are you currently on Warfarin ? / YES / NO
If yes, what hospital administers your warfarin ?
Have you ever served in the armed forces ? / YES / NO
If YES, please complete the following details / Service Number:
Enlistment Date:
Discharge Date:
Are you a registered Carer ? / YES / NO
Are you currently taking any medication of ANY sort on a regular basis? If so, name and dose including home oxygen(Please bring copy of prescription from old surgery)
Are you allergic to any medication?
Name :…………………………………………………….D.O.B………………………………….
Please list any medical conditions that run in your family. If either parent or sister/brothers are deceased, please give cause of death and age at death.
Weight / Height
Have you ever smoked? / YES / NO
Do you currently smoke? / YES / NO
If Yes, how much
Would you like advice on giving up? / YES / NO
If you stopped smoking, when did you give up ?
Physical Activity
1.Please tell us the type and amount of physical activity involved in your work(Please mark only one)
a / I am not in employment ( e.g. retired, retired for illness, unemployed, full time carer)
b / I spend most of my time at work sitting ( such as an office)
c / I spend most of my time at work standing or walking, However, my work does not require much intense physical effort ( shop assistant, hairdresser, security guard, childminder)
d / My work involves definite physical effort including handling of heavy objects and use of tools ( plumber, electrician, carpenter, cleaner, nurse, gardener)
e / My work involves vigorous physical activity including handling of very heavy objects
2. During the last week, how many hours did you spend on each of the following?
None / Some but less than 1 hr / 1 hr but less than 3hr / 3hrs or more
a / Physical exercise such as swimming, jogging, aerobics, football, tennis. Gym, workout etc.
b / Cycling, including cycling to work & during leisure time
c / Walking, including walking to work, shopping, for pleasure .etc.
d / Housework/Childcare
e / Gardening/DIY
3. How would you describe your usual walking pace ? Please mark one box only
Slow Pace
Brisk Pace
Steady Pace
Fast Pace
Name :…………………………………………………….D.O.B………………………………….
FOR WOMEN ONLYWhen did you have a cervical smear test performed and where?
What was the result ?
LANGUAGE CLASSIFICATION Please can you record your first language? This is not compulsory but may help us with your healthcare.
PATIENT ETHNIC ORIGIN QUESTIONNAIREThis questionnaire follows the recommendations of the Commission for Racial Equality and complies with the Race Relations Act.
Please indicate your ethnic origin. Certain conditions are more common in specific communities and knowing your origins will assist in the early identification of these conditions. This is not compulsory, but may help target your healthcare.
Please Choose ONE from section A to E and then tick one box, in that section, to indicate your background.
A. WHITE / Tick
BRITISH
IRISH
ANY OTHER Please specify
B. MIXED / Tick
WHITE AND BLACK CARIBBEAN
WHITE AND BLACK AFRICAN
WHITE AND ASIAN
ANY OTHER Please specify
C. ASIAN OR ASIAN BRITISH / Tick
INDIAN
PAKISTANI
BANGLADESHI
ANY OTHER Please specify
D. BLACK OR BLACK BRITISH / Tick
CARIBBEAN
AFRICAN
WHITE AND ASIAN
ANY OTHER Please specify
E. CHINESE OR OTHER ETHNIC GROUP / Tick
CHINESE
ANY OTHER Please specify
Name :…………………………………………………….D.O.B………………………………….
Alcohol Use Disorder Identification Test
Patient: Because alcohol use can affect your health and can interfere with certain medications and treatments, it is important that we ask you some questions about your use of alcohol.Your answers will remain confidential so please be honest.
Place ancircle the box that best describes your answer to each question.
Questions / 0 / 1 / 2 / 3 / 4
1. How often do you have a drink containing alcohol? / Never / Monthly or less / 2 to 4 times a month / 2 to 3 times a week / 4 or more times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking? / 1 or 2 / 3 or 4 / 5 or 6 / 7 to 9 / 10 or more
3. How often do you have six or more drinks on one occasion? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
4. How often during the last year have you found that you were not able to stop drinking once you had started? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
5. How often during the last year have you failed to do what was normally expected from you because of drinking? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
7. How often during the last year have you had a feeling of guilt or remorse after drinking? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
8. How often during the last year have you been unable to remember what happened the night before because you had been drinking? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
9. Have you or someone else been injured as a result of your drinking? / No / Yes, but not in the last year / Yes, during the last year
10. Has a relative or a doctor or another health worker been concerned about your drinking or suggested that you cut down? / No / Yes, but not in the last year / Yes, during the last year
If you would like to see a CALS (alcohol worker) for advice and guidance please tick
INTERNAL USE ONLY
Description / Tick if seen & copied / Patient InitialsProof of Identity
Proof of Address
Proof of Status ( immigration, student)
Appointment booked / YES / NO
Date of Appointment
Computer Details completed
Confidential DATE OF APPOINTMENT……………….