Lime Tree Surgery New Patient Form
Please complete all details as fully as possible
Dr / Mr / Mrs / Ms / Miss / Other: …………… NHS Number: ………………………………………………………….
Surname: / Previous Surname:First Names: / Date of Birth:
Ethnic Origin: / First Language Spoken:
Address:
Post Code: / Occupation:
Home Tel No: / Work Tel No:
ACCESSIBLE INFORMATION STANDARD
All service providers across the NHS and adult social care system must by law, follow The Accessible Information Standard. The Accessible Information Standard aims to ensure that all people with a disability, impairment or sensory loss have access to information they can understand and the communication support they may need, this includes parents and carers of patients who have such communication needs.
For most of us our preferred method of contact is our home number or mobile number but, for example, if you are hard of hearing that method may not be suitable for you.
If you would prefer us to make contact in another way, please inform us of the most suitable way for us to communicate with you below.
We will then record your suitable method of communication in your medical records.
Do you have a disability, impairment or sensory loss and would prefer practice communications via a specific method more suitable for your needs?
YES NO
If YES, please give details of your preferred method of communication or indicate you would like to discuss:
I give consent to the surgery leaving a message with a third party or on my voicemail requesting that you make contact with us: YES / NO
Mobile No: ………………………………………………………
I give consent to the surgery sending me a text message or leaving me a voicemail: YES / NO
E-Mail Address: ……………………………………………………………………………………………
I give consent to the surgery emailing me: YES / NO
Please note that consent to all the above will be assumed if no options are marked. This arrangement will remain in force until you advise us in writing that you wish to change it.
Marital Status:
Married / Divorced / Single / Living with Partner / Widowed
Next of Kin: …………………………………………………………………………………………………………………………………….
Relationship: ………….………………………………………… Tel No: ……………………………………………………………….
Address: ………………………………………………………………………………………………………………………………………….
PRESENT ILLNESSES / OPERATIONS
Problem / Date□ Asthma
□ Cancer
□ Chronic Kidney Disease
□ Chronic Obstructive Pulmonary Disease
□ Diabetes
□ Epilepsy
□ Heart Disease
□ On Treatment for High Blood Pressure
□ Mental Health Problems
□ Stroke
□ Thyroid Disease /
Problem / Date
Please complete any other past medical history and if possible please provide date.
Try to be as specific as possible e.g. back op – hospital and reason
MEDICATION
Please list all medication you are currently taking and include proof of this medication from your previous surgery. An empty box or a repeat prescription slip will be adequate. This proof is needed before any medication can be issued.
Medication / Dose / Times Per DayWhen requesting your prescriptions would you like to sign up to electronic prescribing? YES / NO
Which pharmacy would you like to collect your medication from? …………………………………………….
IMMUNISATIONS
Please state what immunisations you have had e.g. cholera, diphtheria, influenza, MMR1, MMR2, pneumonia, polio, rubella, tetanus, typhoid, whooping cough etc.
Date / ImmunisationDo you have any allergies: YES / NO
Details and nature of reaction: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..……………………..……………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
If you are female please state what form of contraception you use, if any:
………………………………………………………………………………………………………………………………………………………………….
Date of your last smear: / ……………………………………………………………………………………………….
Details of any abnormal smears: / ……………………………………………………………………………………………….
LIFESTYLE
How much exercise do you take?
Unable to Exercise □ / Avoid Exercise □ / Enjoy Light Exercise □Aerobic Exercise □ / Aerobic Exercise 2/W □ / Aerobic Exercise 3+/W □
Height: ………………………………………………………………… / Weight (kg please): …………………………………………………
Are you:
A smoker □ Ex-Smoker □ Never Smoked □If you are an ex-smoker in which year did you give up? / ………….………….………….………….………….………….……
If you are a smoker, how many a day? / ………….………….………….………….………….………….……
Smoking is detrimental to your health, we provide a smoking cessation service at Lime Tree and we would recommend you use this service to aid you in giving up smoking, should you wish to. For a phone call regarding this service please tick this box □
Please tick the answer that is correct for you:
1. How often do you have a drink containing alcohol?
Never □ (0) Monthly or less □ (1) / Two to Four times a month □ (2)
Two to Three times a week □ (3) / Four or more times a week □ (4)
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
1 or 2 □ (0) 3 or 4 □ (1) 5 or 6 □ (2) 7 to 9 □ (3) 10 or more (4)
3. How often do you have six or more drinks on one occasion?
Never □ (0) Monthly or less □ (1) / Two to Four times a month □ (2)
Two to Three times a week □ (3) / Four or more times a week □ (4)
Alcohol can be detrimental to your health; we can provide help to those whose drinking poses a health risk. Please book an appointment with a GP if you would like to discuss this further.
Do you have a Carer: YES / NO
Name of Carer: ……….……….……….……….……….……….……….……….……….……….……….……….……….……….……….……….
Are you a Carer: YES / NO
Name of person you care for: ……….……….……….……….……….……….……….……….……….……….……….……….……….…..
Office use; Carers forms given; date: ………………………
Rec Initials of staff member: ………………………. / Office use; Scheduled task sent to Carers Lead
Admin
BLOOD PRESSURE
If you are a 16 or over, please take your blood pressure using the machine in the waiting room
The machine will print out your reading on a ticket, please write your name and date of birth on this and hand it in to a receptionist with this sheet.
Access to online Services
If you are interested is using our online services, to book appointments, order repeat prescriptions and gain access to your summary medical record. Please ask for a Registration form at reception.
Please sign below to state that the details you have entered on this form are correct and you are happy for this information to be entered on your medical records.
Signed:
Date:
Thank you for completing this form.