By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy.
Also, by sending this form you are indicating your agreement that the surgery may contact you by email or telephone to discuss the information contained in this form.
If either of these points concerns you or you disagree in any way then you should use another method of notifying us of your change of contact details.
Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.
Your contact details
Previous surname (if relevant)
Date of birth
Home tel. (without spaces)
Mobile tel. (without spaces)
Information about you
What is your height?
What is your weight?
What is your first language?
Do you need an interpreter?
If other, please specify
Your previous GP name and address
Proof of identity and address provided
If other please specify
Please list any serious illnesses / operations / accidents / disabilities (and for women any pregnancy related problems) and the year they took place
Have you ever suffered from? (tick as appropriate)
If yes, please state the year(s) when were you first diagnosed?
Please list any medicines being taken and the amount:
Are you registered disabled?
If yes, please give details
Are you allergic to any medicines?
If so, which?
Have you ever refused treatment/screening of any kind?
If so, what and when?
Have you ever suffered from any of the following? (tick as appropriate)
If yes to any of these, please state the year(s) when were you first diagnosed
Please give details of any other mental health issues
Are you receiving or have you received any treatment or therapy? (If yes please give details of your care and when you received it)
Do you have a carer?
If yes please give details
Are you a carer?
If yes please give details
A Living Will is documentation regarding your personal wishes in respect of medical intervention at the time of serious illness.
Do you hold a Living Will?
Have you ever had a cervical smear?
If 'yes', please state when, where and the result
Do you smoke
If 'No', have you ever smoked?
If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?
1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits
MEN: How often do you have EIGHT or more drinks on one occasion?
WOMEN: How often do you have EIGHT or more drinks on one occasion?
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
How often during the last year have you failed to do what was normally expected of you because of drinking?
In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?
Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer.
For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)
Have you had a flu vaccination? Enter date or 'never':
Have you had a pneumococcal vaccination? Enter date or 'never'
Permissions and submit
Please confirm you are happy for us to contact you from time to time, via email and/or SMS, with practice news, health advice and/or appointment reminders.
Signature (you will be asked to sign this form when you visit the practice)
Some required Fields are empty Please check the highlighted fields.
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