Download dr neil turner - North Road Surgery

NORTH ROAD SURGERY
77 North Road, Kew, Surrey. TW9 4HQ
Tel: 02088764442. Fax: 02083922311
www.northroadsugery.nhs.uk
DR. WARWICK BEALES: G9001787
DR. ALEXANDRA STRACHAN: G8137566
DR MOLIN NAVAMANI: G9237467
DR JYOTSNA MAGAPU:G9240273
ADULT(From 15 years of age)
Welcome to North Road Surgery.
Please note:You will only be able to make an appointment with the Practice Nurse, Health Care
Assistant or Doctor after five working days from receipt of this form.
Surname:……………………………………………………............. Mr/Mrs/Miss/Ms/Dr/Other…….....…
Forename(s): ………………………………..……… Status: Single/Married/Separated/Divorced/Widowed
Ethnic Origin: Please tick one of the following:
A
B
C
D
E
F
G
H
J
White British
White Irish
Any other White background
Mixed White and Black Caribbean
Mixed White and Black African
Mixed White and Asian
Any other mixed background
Indian (Asian or Asian British)
Pakistani (Asian or Asian British)
K
L
M
N
P
R
S
Z
Bangladeshi (Asian or Asian British)
Any other Asian background (Asian or Asian British)
Caribbean (Black or Black British)
African (Black or Black British)
Any other Black background (Black or Black British)
Chinese
Any other ethnic category
Not stated
First Language: .......…………………………………………………………………………………………....
Please register me for online services(Appointments, prescription requests): Yes
No
E-mail Address:…………………………………………………………………………………….
What serious illnesses have you had? Please list any past and current medical problems and operations:
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
Are you allergic to any medications? Please list ……………………..…………………………………
……………………………………………………………………………………………………………..
Please list any tablets, medicines or other treatments you are taking (including those bought over the counter):
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
Are there any serious illnesses which affect members of your family? ……………………………………
Continued over
When was your last tetanus immunisation? ………………………………………………………………..
Please list any other recent immunisations, e.g. Typhoid/hepatitis ………………………………………...
……………………………………………………………………………………………………………….
Height:
………………………………………. Weight:
……………………………………
Are you a current smoker? YES/NO
If yes, how many per day?....................................................
We strongly advise you to stop smoking and can help you do this. Please enquire at the practice for details.
Have you ever smoked? YES/NO
When did you stop smoking: ……………………….…
Do you drink alcohol?
How much/day? ……………………………………….
YES/NO
What sort of exercise do you take? ………………………………………………………………………….
Please describe any special diet you are following: ……………………………………………………..…..
Are you a CARER or do you HAVE A CARER (please circle applicable)
Name of the person who is cared for OR is the carer
First/Last Name____________________________________________
Date of Birth ____/____/________ Telephone No’s __________________________________________
Address______________________________________________ Post Code_______________________
To be Completed by Adult Females only
Cervical Smear Screening
Date of last cervical smear test: ____________________
Result of last cervical smear test: ___________________
Breast Screening (for over 50s)
Date of last mammogram: _________________________
Result of last mammogram: ________________________
Summary Care Records have been introduced to improve the safety and quality of patient care. It enables
health care providers to view your medication(last 12 months) any allergies and any adverse reactions, when
you are being treated in an emergency, whilst away from home or your normal practice is closed. You
automatically have a Summary Care Record if you are registered with a GP practice in England.
If you wish to opt out please ask reception how to obtain opt out form.
Patient’s signature: ………………………………………………………. Date: ……………………….
NB: In order to register you must bring a photocopy and the original of the following:
 Valid Passport
 Utility Bill or Bank Statement (less than 3 months old).
We invite all newly registered patients to have a New Patient Health Check or NHS Health Check. Please ask reception for
details.
You can help us to improve our service and have your say by joining our Patient Participation Group. We will contact you
from time to time to ask for your opinion about various aspects of our service. If you would like to join, please leave your
e-mail address:
____________________________________________________________________________________
For practice use only: Seen -
Passport / Visa
Utility Bill / Bank Statement or other
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