Woodseats Medical Centre
Woodseats Medical Centre – New Patient Information
After registering with the practice you will need to attend the morning drop in clinic (between 08.30 & 10.30 Mon-Fri) for a blood pressure check and to bring a urine sample with you.
If you are on repeat medications you will need to bring in the back of an old prescription or something with full details of your repeat medication on before these can be issued. Please ensure when registering that you have at least 2 weeks’ worth of medication.
Please complete as fully as possible and return to the practice.
Past Medical History
· Have you any ongoing minor or major illnesses? Please list even if you no longer think they
are important or don’t take medication anymore. Please write down when they started. Please list any
major past illnesses that are now resolved including infections or episodes of depression. Include any past operations.
Date: Problem
…………………………………………………………………………………………………………………………………………………………………………………………………………
Repeat Medication
· Are you on any regular medication including those bought direct from pharmacist? – please attach the list from your last doctor or list on separate paper
Allergies
· Please list any medication that has caused an allergic response or had to be stopped because of side effects. It would be helpful to know when this happened and what the effect(s) where.
………………………………………………………………………………………………..……
Contraception
· Please write down the form of contraception you currently use. This includes sterilisation or vasectomy.
………………………………………………………………………………………………..
Are you due a Cervical Smear? – if so please make an appointment with practice nurse as soon as is convenient.
Previous Pregnancies (where applicable)
· Please write down details of your previous pregnancies (including miscarriages or terminations).
For your children could you write down the date, whether it was a normal, forceps, suction
or caesarean delivery, the sex and name of each child?
……………………………………………………………………………………………………
Smoking
· Never smoked Passive Smoking When/Where? …… ………………….…
· Ex-Smoker Date gave up? ……………………… How many/how long? …….….…
· Current Smoker How long for ………………………………………………….…………………
· How many cigarettes a day? …………….… How many cigars a day? ……………….…
· If you would like help to stop smoking please tick this box (if you do not tick this box we will record
that you have declined the offer of smoking cessation help.)
Alcohol Consumption [136]
· How many units per week? ……………………………………………………………...………… ..
(1 unit = 1 standard glass wine/half a pint of bitter/1 PUB measure of spirit. 1 pint of lager is usually
2.5 units and premium lager, eg Stella is 3 units per pint) Teetotaller Ex-Drinker
Exercise – Describe how much exercise you do
……………………………………………………………………………………………….……
Diet – Describe your diet, how healthy is it?
Good, moderate or poor? Vegetarian or Vegan? Gluten free /Lactose free?
……………………………………………………………………………………………….
Height (if known) ……………………… Weight (if known) ……………………
Family History of following conditions in your parents, brothers or sisters, or children: (please tick which apply – please indicate who has condition and what age they were when it started)
Diabetes ……………………………………………………………………………..……
Heart problems such as angina or heart attack………………………………………..…
Stroke …………………………………………………………………………….…….…
Cancer …….…………………………………………………………………………………
Is there anything else we need to know? ………………
Do you look after someone? Yes No (Please tick appropriate box)
Does someone look after you? Yes No (Please tick appropriate box)
PLEASE HAND THIS FORM TO THE HEALTH CARE ASSISTANT WITH YOUR URINE SAMPLE WHEN YOU
ATTEND