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St Luke’s Medical Practice Carluke Health Centre 40 Chapel Street Carluke ML8 4BA Tel: 01555 752150 Identification: Medical Card Passport Driving Licence Birth Certificate Other (Detail below) Proof of address (Utility Bill): _______________ Fax: 777455 Prior to joining the practice list it is very important that all patients over 16 years of age attend the practice nurse for a New Patient Medical Check. Please complete this short, confidential questionnaire and make an appointment at Reception. Please bring a urine sample with you. Surname Forename DOB Address Post Code Home Tel Mobile Tel Place of Birth Date of entry to UK Male Female Marital Status Occupation Ethnic Origin: Please the relevant box. Ethnic Origin affects risk factors for various diseases: White Scottish Indian Black Caribbean Other White British Pakistani Black African White Irish Bangladeshi Other Black ethnic group Other White ethnic group Chinese Other ethnic group Other ethnic mixed group Other Asian ethnic group Decline response Are you suffering from any illnesses at present? No Yes If Yes, please detail below Are you taking any medicines of any kind at present? Acute Prescriptions No Yes If Yes, please detail below Other Repeat Medication Do you have any allergies? No Yes If Yes, please detail below Have you had any serious illness in the past? No Yes If Yes, please detail below Have you had any operations in the past? No Yes If Yes, please detail below Are there any common illnesses within in your family? Illness No Yes If Yes, please detail below Relative Age Diagnosed Diabetes Coronary Heart Disease Asthma Other: Smoking Status? Never Ex Current Current smokers Do you ever take alcohol? No Yes If Yes, how much per week? When did you last have a tetanus immunisation? Do you have a carer? No Yes Name: Relationship: (Excluding employed or carers from a Voluntary organisation) Do you care for someone who is frail or unwell? (eg Family Member or friend on an unpaid basis) No If Yes, Name: Per day Per week Yes Females Only Have you had a cervical smear test? Signature: No Yes Date of last smear: Date: Page 1 of 2 Forename: Date: Surname: Date of Birth: SHOULD YOU BE TESTED FOR BLOOD BORNE VIRUSES? (Hepatitis B or C, HIV) Blood borne viruses are infectious and can lead to various problems including liver disease. The virus is found in the blood of persons who have this type of infection and is spread through contact with the blood of an infected person. This may result from sexual contact, the use of contaminated needles or equipment or receiving a transfusion of infected blood or blood products before 1992. Treatment is available for these infections. Testing for blood borne infection is an enhanced medical service provided by the Practice to those deemed at increased risk of contracting this type of infection, supported by NHS Lanarkshire. The following statements will help determine if you should be tested for blood borne infection. You can check any box that applies to you. I am in one of the following groups, but I have been tested and have been at no further risk since then I am in one of the following groups, but I do not wish to disclose which one I have injected recreational drugs and/or used cocaine (even if it was only once or many years ago) I received blood clotting factor concentrate manufactured before 1987 (e.g. for haemophilia) I received a blood transfusion or organ transplant before 1992 I received a blood product from a donor who later tested HIV, Hepatitis C or B positive My mother has/had HIV, Hepatitis B or C I have a sexual or household contact that is positive for HIV, Hepatitis B or C I have or have had a sexually transmitted infection I am a man who has had sex with another man I have had multiple sexual partners I have HIV or Hepatitis B or Hepatitis C infection I or my family originate from a part of the world where HIV, Hepatitis B or C is more common I have had medical or dental care in a country where HIV, Hepatitis B or C is more common I have had tattoos or body piercing in circumstances where infection control methods have not been ideal (e.g. the use of contaminated equipment) Not applicable Please return this form to the Practice and your GP or Practice Nurse can discuss this with you in confidence. For more information go to www.stlukesmedicalpractice.co.uk