Princess street group practic registration form

LEIGHTON ROAD SURGERY
PATIENT INFORMATION QUESTIONNNAIRE
Your answers will help us to plan services that can help to improve your health. All information you
provide will be treated in strict confidence and in accordance with all data protection legislation.
PERSONAL DETAILS (Please complete in block capitals as appropriate)
Family Name :.First Name:.

Date of Birth.
Occupation………………………………………………………………….
Home telephone . Work telephone:..

Mobile telephone:.Email address……………………………………………
Please indicate (by circling) which number you would prefer us to contact you on during the day
Can we send you text reminders of booked appointments? Yes/No (please circle)
Can we email you with our Newsletter Yes/No (please circle)
a student □ a refugee □ homeless □

Name of Next of Kin :.Relationship to you:.

Next of kin contact telephone:.

Is your Next of Kin registered at this practice? Yes /No

WHAT IS YOUR ETHNIC GROUP?
White
Asian or Asian
Black or Black
Other ethnic
Prefer not to state ethnic group □
What is your first language?..
Do you need us to book you an interpreter? □ Yes □ No


DISABILITY/SPECIAL NEED
Do you have any disability or special need, including visual or hearing impairments? If so please
describe below
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………

YOUR MEDICAL HISTORY
Have you had or do you now have any of the following illnesses?
Please tick the box if you have any of
Operations please describe

MEDICATION
If you need regular prescriptions please make an appointment to see a doctor before your
next supply is due. We are unable to issue any prescriptions until you have discussed your
medication with the GP.

Do you have any drug allergies
………………………………………………………………………
RW/C/Publications 08/2010

FAMILY MEDICAL HISTORY
Please give us some information about your family


YOUR HEALTH
What is your weight? .What is your height? .
Regular exercise and a good diet help to keep your heart healthy. Ask us for advice.
Have you had your blood pressure measured in the last 5 years?
Do you know what your reading was? ./. or Normal □
If you are aged 45 or over you should have your blood pressure checked every 5 years. If your last
blood pressure check was abnormal or if you cannot remember the result please make an
appointment to see the Health Care Assistant for a Blood Pressure check.

EXERCISE
Would you describe your exercise level as:
Heavy exercise □
In your own words how much exercise do you get?
………………………………………………………………………………………………………………….


DIET
Would you describe your diet as:
Vegetarian □
In your own words what does your diet usually contain
………………………………………………………………………………………………………………….

ALCOHOL

Do you drink alcohol?

If yes, how many units do you normally drink per week? .

(One unit = half a pint of normal strength beer or 1 small glass wine or 1 single measure of spirits)
How often do you have a drink that contains alcohol?

How many alcoholic drinks do you have on a typical day when you are drinking? How often during the past year have you found you were not able to stop drinking once you had started? How often during the past year have you failed to do what was normally expected of you because of drinking? Has a relative, friend or doctor been concerned about your drinking or suggested you cut down? More than 21 units per week for men and 14 for women can damage your health. Ask a doctor or nurse for more advice.
Do you smoke cigarettes? Yes/No
If yes, how many cigarettes do you smoke every day?

If no, but you have smoked in the past, when did you stop? .

How many did you smoke every day before you stopped? .

Tobacco smoking is the biggest cause of preventable illness and death. If you want help to
stop we can refer you to a smoking cessation advisor.
CONTRACEPTION
Do you use contraception? Yes/No
What do you use?

We offer a full range of contraception services, including emergency contraception (the
‘morning after' pill).


SEXUAL HEALTH
Sexually transmitted infection is on the increase. Very often people do not know they are
infected.
If you would like a sexual health check please book an appointment at our Sphere Clinic.
phone 01525 379684.

CARER DETAILS

A carer is a person who looks after a relative, friend or child with a physical or learning disability; or
who has a mental health problem, a long-term illness or who is frail. This definition does not
include those who are paid carers.
Are you a carer?

Do you have a carer?

Your carer's name: .

Your carer's telephone number:.

THIS SECTION IS FOR WOMEN ONLY TO COMPLETE


Women who are sexually active and aged between 25 and 49 should have a cervical
smear test every 3 years. Women aged between 50and 65 should have a cervical smear
every 5 years. We have a national screening programme that automatically invites ladies to
have a smear test.

What was the date when you had your last smear done? . Where was it done? In the UK □ Abroad □ What was the result? Normal □
If your smear test is due or you are 25 or over and have never had a smear test please book
an appointment with a Practice Nurse.

FOR PRACTICE USE ONLY
Computer Number:
Form checked & taken
Entered by:
Date entered:
Please pass smear sheet to administrator

Source: http://leightonroadsurgery.co.uk/practices/leightonroad/Leighton-Road-Patient-Information-Form-Aug-2010-updated.pdf