Patient Information Sheet – Confidential
Surname……………………………Tel: Home…………………………….
Mobile……………..……………
Forename ……………………………….Date of Birth…../……/……
Address…………………………………Occupation……………………
……………………………………………
Next of Kin -Name …………………………Relationship…………………………
Address ……………………………………………. Telephone ……………………………….
Average no of units of alcohol per week…………units [1 unit = half a pint of beer, a glass of wine or a pub measure of spirits]
Smoking Status:Never Smoked Tobacco [1371]
Ex Smoker [137S]
Current Smoker [137R]
Do you care for someone who is old
or who has a disability?yesNo
Do you have a disability that we
should be aware of?yesNo
If yes, please give details below:
Illnesses & Operations Date of diagnosis
1……………………………………………………
2……………………………………………………
3……………………………………………………
4……………………………………………………
5……………………………………………………
6……………………………………………………
Regular Medicines
1…………….………………2………..………………....3………………………….….
4……………………………5…………………………….6………………………………
Do you have an allergy to any medicines? If yes, please give details below:
AllergySeverityCertaintyReaction
(e.g. penicillin)(mild/moderate/severe)(Possible/likely/certain)(Swelling, rash etc.)
…………………………………………………………………………
…………………………………………………………………………
FamilyState of HealthAge of DeathCause of Death
Father:………………………………………………………
Mother:………………………………………………………
Siblings:………………………………………………………
Spouse:………………………………………………………
Children:………………………………………………………
Have you or anyone in your family ever suffered from:
YouYour Family [Parents, siblings]
High Blood Pressure
Heart Disease
Stroke
Asthma
Diabetes
Cancer – Breast
Cancer – Ovary
Cancer – Bowel
Kidney Disease
Depression
Chronic Lung Disease
Epilepsy
Dementia
Atrial Fibrillation
Thyroid Disease
When were you last immunised against
Tetanus [injection]………………………..Polio [drops]………………………………
Signed………………………………….Date……………………………
Dr Wilson & Partners
Stockbridge Health Centre
1 India Place
EDINBURGH EH3 6EH
Cervical Screening Team
Room A.01.27
Bioquarter
9 Little France Road
Edinburgh
EH16 4UX
Practice Reference: S70408
To enable us to update our Lothian Module for Cervical Screening I would be grateful if you could complete the details below.
Full Name………………………………………………………………………………..
D.O.B………/………/………
Address………………………………………………………………………………...
Test Date (e.g. 01/01/2006) ………/………/……… (Please give minimum of date and year)
Where was test done (e.g. Doctors, Family Planning?): ………………………………….
Result of test (please circle):NegativePositive
What is your recommended recall period (please circle):
3 yearly
YearlyPlease give details why …………………………………………………..
6 monthlyPlease give details why …………………………………………………..
Other Please give details why …………………………………………………..
Signature……………………………………..Date………/………/………
Reviewed: January 2016