Parishes Bridge Medical Practice

Parishes Bridge Medical Practice

Last Cervical Smear Test (Females Age 20-64 years of age)

Date / Result
Normal / Abnormal

Immunisation Status – Children under 6 years of age:

We must have complete details of vaccinations and immunisations already performed. Children may not be registered until this information has been recorded. If you cannot remember the dates, please give approximate dates and bring in your Childs’s Health Record book for checking. Please attach list with dates on a separate page.

Statement of Ethnicity

British / Irish
Any other White Background
White /Caribbean / Black/Caribbean
White/African / Black/African
Asian / Any other Asian Background
Any other Mixed background / White/Asian (mixed background)
Pakistani/British Pakistani / Bangladeshi
Indian/British Indian / Any other Black Background
Chinese / Any other Ethnic Group
First Spoken Language

Total Number in Household

ADMIN USE ONLY / Proof of address seen
Yes/No / BP taken here or taken in previous practice
STAFF INITIALS =

Updated 19.10.2012

ParishesBridge Medical Practice

West Byfleet Health Centre, Madeira Road,

West Byfleet, Surrey. KT14 6DH

Tel: 01932 336933 Fax: 01932 355681

Welcome to our Practice

Please complete all parts of this form, as applicable, with as much information as possible to help us to register you with our Practice (please complete on separate paper if insufficient space). It is especially important to tell us about any serious illnesses and any regular medications.

Please read our Practice Booklet with regards to GP training, research and home visits.

In order to complete your registration promptly please supply two of the following documents:

Current Passport

Utility bill/rent agreement with your new address on

Visa

Photographic Driving Licence

As part of your New Patient Application it is a requirement that you make a Health Check Appointment with a Practice Nurse, this will take just 10 minutes. If you require a repeat prescription you will need an appointment with a GP, please take a complete list of all your medications with you.

Your Name
Your Mobile and Home
Tele No.’s
Next of Kin
Next of Kin Tel. No.
Marital Status / Single / Married
Divorced / Widowed
Separated / Living with Parents

Alcohol (1 Unit = ½ pint of beer, 1 small glass wine or 1 single spirit)

How many units of alcohol do you drink per week =

Please circle your answer

How often do you have a drink that contains alcohol? / Never / Monthly or less / 2-4 times per month / 2-3 times per week / 4+ times
per week
How many standard alcoholic drinks do you have on a typical day when you are drinking? / 1-2 / 3-4 / 5-6 / 7-8 / 10+
How often do you have 6 or more standard drinks on one occasion? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
Height
Weight
Waist Measurement

Operations

Date / Operation Type

To be competed for all children aged 16 years or under:

Parent/Carer
Name and Address of
Nursery/School attended with Postcode
Are you a carer of Disabled/Invalid/Elderly / Yes / No
If Yes, name of person cared for
Occupation/Previous Occupation
Employers Tel. No.

Family Medical History

Heart Attack/Disease
Ages over 60 years
Ages under 60 years / Cancer
Stroke / Diabetes
Glaucoma / Epilepsy
Hypertension / Asthma

Personal Medical History

Heart Disease / Asthma
High Blood Pressure / Cancer
Diabetes / Other (specify)

Allergies

/

Yes

/

No

Please specify

Current Medication

Medication Name

/

Dose

Smoking Status

Never Smoked
Ex Smoker / Date Stopped
Smoker / Number per day
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