Download Prior to joining the practice list it is very important that all patients

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