ZETLAND MEDICAL PRACTICE

Patient Health Summary – DATE…………………………………

Please complete as much as possible of this form and return to reception with your registration form.

NAME………………………………………………………...... Date of BIRTH……………………......

ADDRESS…………………………………………………………………………………………………………………

……………………………………………………………………….. POSTCODE:………………………......

TELEPHONE NO:……………………………………... MOBILE………………………………………...

EMAIL ………………………………………………… MARITAL STATUS………………………………

OCCUPATION:………………………………......

NEXT OF KIN…………………………………......

NEXT OF KIN CONTACT DETAILS…………………………… ……………………………………………………..

NAME OF SCHOOL FOR ALL UNDER 16s……………………………………………………………………………

'A carer is a person of any age, adult or child, who provides unpaid support to a partner, child, relative or friend

who couldn't manage to live independently or whose health or well being would deteriorate without this help.

this could be due to frailty, disability or serious health condition, mental ill health or substance misuse.'

DO YOU CARE FOR SOMEONE WHO IS PHYSICALLY OR MENTALLY DISABLED? YES NO

If yes, have you involved Social Services? ......

Do you have a Learning Disability YES NO If you have a support worker please give details:

………………………………………………………………………………………………………………......

Registered blind YES Date registered ...... NO

Partially Sighted YES NO

Hearing aid user YES NO Any communication needs …………………………….

DO YOU HAVE A CARER YES NO If YES please complete details below

NAME…………………………………………………

RELATIONSHIP……………………………………….

CONTACT DETAILS…………………………………..

ALLERGIES: List all known allergies:

HEIGHT:………………………………...... WEIGHT:……………………………………

SMOKING STATUS:

Smoker: Cigs per day: ...………... Pipe smoker:

Ex smoker: approximate date stopped...... Never Smoked

Current Drinker Ex Drinker Lifelong Teetotal

ALCOHOL: Approximately how many units do you drink a week?

1 unit = ½pint beer/lager/cider, 1 glass of wine, 1 measure of spirits, 1 small glass of sherry

For the following questions please circle the answer which best applies.

1 drink = ½ pint beer or 1 glass of wine or 1 single spirit.

1. How often do you have eight or more drinks on one occasion?

NeverLess thanMonthlyWeeklyDaily or

Monthlyalmost daily

2. How often during the last year have you been unable to remember what happened the night before because you had been drinking?

NeverLess thanMonthlyWeekly Daily or

Monthlyalmost daily

3.How often during the last year have you failed to do what was normally expected of you because of your drinking?

NeverLess thanMonthlyWeeklyDaily or

Monthlyalmost daily

4. Has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?

NoYes, but not inYes, during

The last yearthe last year

MEDICATION:ATTACH a repeat request slip from your previous practice or medication boxes with chemist labels

Practice Procedure re Repeat prescriptions: We now generate repeat prescriptions electronically, these are sent directly to the nominated pharmacy of your choice. Please contact your chosen pharmacy ask them to arrange this.

If there is no preference prescriptions will be kept at the surgery for collection.

Please record your ethnicity and preferred first language:

White British9S10.Pakistani 9S7

White Irish9S11.Bangladeshi 9S8..

White – Any Other Ethnic Group*9S12.Asian – Any Other Ethnic Group 9SH..

Black/White Caribbean mixed9SB5.Black Caribbean 9S2..

Black/White African mixed9SB6.Black African 9S3..

Asian/White mixed9SB2.Black – Any Other Ethnic Group 9SG..

Any Other Mixed Ethnic Group9SB4.Any Other Ethnic Group* 9SJ..

Indian9S6..

.

PREFERRED FIRST LANGUAGE ………………………………………………………………

*If you wish to supply additional details, enter here ......

If you do not want your ethnicity recorded tick here  9SD