Dr R Pugh
Dr I Richards
Dr S Sardar
Dr J Courtney
Dr W Frew
Dr G Haveron
Associate GP:
Dr D Simpson /

The Surgery

Dr Pugh & Partners

/ 31 Portland Road
Kilmarnock
KA1 2DJ
Tel: 01563 522118
Fax: 01563 573562

CONSENT TO CONTACT

Access to Medical Records

Name / DOB
Address
Telephone Number / NHS Number

I______give consent for staff at Dr Pugh & Partners to contact my

registered GP to access my health records.

Patient

Print Name / Date
Signed

Staff Member

Print Name / Date
Signed
Dr R Pugh Dr W Frew
Dr I Richards Dr S Sardar
Dr J Courtney Dr G Haveron
Dr D Simpson /

The Surgery

Dr Pugh & Partners

/ 31 Portland Road
Kilmarnock
KA1 2DJ
Tel: 01563 522118
Fax: 01563 573562

NEW PATIENT QUESTIONNAIRE

It can take considerable time for your medical records to be sent to a new practice. This questionnaire will give the doctors basic information about your medical history. Please complete one for each family member joining the practice.

NAME / DOB
ADDRESS
TEL NO / OCCUPATION or CURRENTSCHOOL
SOCIAL STATUS / Married/Civil partnership / Single / Separated / Divorced / Widowed / Co-habiting
MEDICAL HISTORY / YES / NO / Further Comment
Allergies
Epilepsy or Blackouts
High Blood Pressure
Heart trouble
Chest trouble e.g.Asthma / Date of diagnosis
Kidney or Bladdertrouble
DepressionorMental Breakdown
Diabetes
Surgical Operations
Other Hospital Admissions
MEDICAL HISTORY / YES / NO / Further Comment
Do you smoke / If yes, do you wish smoking cessation advice
Yes No
If yes please ask the receptionist for a leaflet
______
Office use only
Leaflet given
Have you ever smoked / Date stopped smoking______
Alcohol Consumption / Weekly Consumption
FAMILY HISTORY(first degree relative eg parent or sibling) / YES / NO / Not known/Not applicable
Stroke
Diabetes
High blood pressure
Heart attack before age 60
Heart attack after age 60
MEDICATION / YES / NO / Comment
Are you regularly taking any medication
If using an inhaler, date of last prescription / If yes, please attach a copy of your Re-order list
HOUSBOUND STATUS / YES / NO / REASON
Are you housebound
WOMEN / YES / NO / TYPE OF ADVICE REQUIRED
Do you wish contraceptive advice
YES / NO / YEAR
Have you ever had a cervical smear
COMMUNICATION WITH THE NHS
If English is not your first language, do you need an interpreter?
Yes No
If you do need an interpreter what language do you speak?
Please state …………………………………………………….
If hearing impaired, do you require a sign language interpreter?
YesNo
Are you registered Blind?YesNo
Are you visually impaired?YesNo
If you have a visual impairment, would you prefer information by:
Letter with Large FontYesNo
EmailYesNo
PhoneYesNo
Fax Yes No
Are you a Carer with responsibility for a family member / friend / neighbour? YES/NO
Do you have a Carer YES/NO
If yes please speak with the receptionist – you will be asked if you wish to be referred to our member of staff from the Princess Trust Support for Carers.
Have you ever been registered with this Practice before?YES/NO
Have you been registered with another practice within Kilmarnock in
the last 6 months?YES/NO
If yes which practice?…………………………………………………………………………………..
NEXT OF KIN DETAILS
Name
Address
Contact Tel No
Relationship
Reading language:

ETHNICITY

This short questionnaire will give surgery staff some basic information about your communication support needs and ethnicity to support your health care.

Please ask a member of staff if you need more explanation.

We should be grateful if you could complete one for each family member within/joining the practice.

Name ……………………………………………….. DOB _ _ / _ _ / _ _

Do you need an interpreter or sign language support? Yes No

If you do need an interpreter what language do you speak?

Please state …………………………………………………….

What is your ethnic group?

Choose ONE section from A to E then tick ONE box which best describes your ethnic group or background

A White

□Scottish

□English

□Welsh

□Northern Irish

□British

□ Irish

□Gypsy/Traveller

□Polish

□Any other white ethnic group, please write in…………………………………..

B Mixed or multiple ethnic groups

□ Any mixed or multiple ethnic groups

C Asian, Asian Scottish or Asian British

□Pakistani, Pakistani Scottish or Pakistani British

□Indian, Indian Scottish or Indian British

□Bangladeshi, Bangladeshi Scottish or Bangladeshi British

□Chinese, Chinese Scottish or Chinese British

□Other, please write in……………………………………………….

D African, Caribbean or Black

□African, African Scottish or African British

□Caribbean, Caribbean Scottish or Caribbean British

□Black, Black Scottish or Black British

□Other, please write in………………………………………………………………

E Other ethnic group

□ Arab

□ Other, please write in………………………………………………………………..

If you do not wish to give this information, please tick here

Version 5 – July 2016

Z:\New patient information and registration\New Patients 2016 onwards\NP New Patient Questionnaire and Ethnicity.doc