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?yesNo

Do you have a disability that we

should be aware of?yesNo

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