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WESTWOOD MEDICAL CENTRE New Patient Health Questionnaire for Adults Your Contact Details Mr Mrs Miss Ms Other Surname Date of Birth First Names Occupation Previous Surnames Home Address Postcode: Home Tel Mobile Work Tel Email Fax Alternative Communication Format – Preferred Contact Method – Please tick one box No Preference Home tel. number Work tel. number Mobile tel. number Email address Letter to home address Letter to temporary address Fax number What is your first language? Ethnic Group White British Irish Other Please State: Black Caribbean African Other Please State: Asian Indian Pakistani Other Please State: Chinese Mixed White + Black Caribbean White + Black African White + Asian Other Please State: Information About You What is your height? What is your weight? Blood Pressure? Medical Information 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) Epilepsy High Blood Pressure Heart Attack/Stroke Cancer Eczema/Hay Fever Mental Illness Yes Yes Yes Yes Yes / / / / / No No No No No Blindness/Glaucoma Diabetes Depression Asthma COPD Yes Yes Yes Yes Yes Please list any medicines being taken and the amount: Are you allergic to any medicines and if so, which? Yes / No Carers Do you have a carer? (If yes please give details) Yes / No Are you a carer? (If yes please give details) Yes / No Women Have you ever had a cervical smear? (Please state the last date) Yes / No / / / / / No No No No No Smoking Do you smoke? Yes / No If 'No', have you ever smoked? Yes / No If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week? Would you like advice on giving up smoking? Yes / No Alcohol 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 SIX or more drinks on one occasion? Never Less than Monthly Monthly Weekly Daily How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never Less than Monthly Monthly Weekly Daily How often during the last year have you failed to do what was normally expected of you because of drinking? Never Less than Monthly Monthly Weekly Daily 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? No Yes, on one occasion Family History Yes, more than once Relative Heart disease/angina (over 60) ....................................... Heart disease/angina (under 60) ...................................... Stroke .............................................................. High blood pressure ................................................. Diabetes ............................................................ Asthma .............................................................. Cancer (type) ....................................................... Mental illness ...................................................... Next of Kin Please give relationship, name, address and telephone number of next of kin SUMMARY CARE RECORD Patient Name………………………………………………………………………………………………………… …………………. NHS Number…………………………………………………. Birth…………………………………………………….. Date of WESTWOOD MEDICAL CENTRE offers its patients the choice of having a Summary Care Record. The new NHS Summary Care Record is being introduced to help deliver better and safer care and give you more choice about who you share you healthcare information with. WHAT IS THE NHS SUMMARY CARE RECORD? The NHS Summary Care Record will contain basic information introduced to help about any allergies you may have, unexpected reactions to medications and any prescriptions you have recently received. The intention is to help clinicians in Accident and Emergency departments and ‘Out of Hours’ health services to give you safe, timely and effective treatment. Clinicians will only be allowed to access your record if they are authorized to do so and, even then, only if you give your express permission. You will be asked if healthcare staff can look at your Summary Care Record every time they need to, unless it is an emergency, for instance if you are unconscious. You can refuse if you think access is unnecessary. CHILDREN UNDER THE AGE OF 16 Patients under 16 years will not receive this letter, but will have a Summary Care Record created for them unless their GP surgery is advised otherwise. If you are the parent or guardian of a child then please either make this information available to them or decide and act on their behalf. You do not have to have a Summary Care Record, although you are strongly recommended to consider this choice. If you decide to proceed, but at any time in the future you, or a child you are responsible for, change your mind and choose not to have a Summary Care Record, all you need do is to write to your surgery informing them of you decision to “Opt-out”. If you have already told your Surgery that you wish to “Opt-out” and you wish this to remain in place you need take no further action. PLEASE TICK BOX ONLY IF YOU DO NOT WANT A SUMMARY CARE RECORD: NO I would not like to have a Summary Care Record If you want a Summary Care Record you do not have to do anything, it will automatically be created for you. If you are Opting Out of having a Summary Care Record please sign below. Signed by Patient…………………………………………………………………………………………..