Download WORTHING MEDICAL GROUP

NEW PATIENT MEDICAL HISTORY - Integrated Care Home Service
PLEASE COMPLETE ALL DETAILS AS FULLY AS POSSIBLE
Title
Dr/Mr/Mrs/Ms/Other
Surname
Previous
Surname
Forenames
Calling name
Date of birth
Place of birth
Full home address
including postcode
Telephone numbers
Home:
Mobile:
NHS number
Your previous address
including postcode
Previous Doctor - Name
Address
If from abroad, date of arrival in
the UK
If ex-armed forces:
Address before enlisting
Dates of service (from/to)
Next of kin - Name
Address
Tel number
Relationship to you
Please circle as appropriate
Nursing home resident
Residential home resident
PAST ILLNESSES / OPERATIONS
Please include all except minor problems and give dates (even approximately)
Please continue overleaf if necessary
DATE
PROBLEM
PLEASE LIST ALL YOUR CURRENT MEDICATION
Please list anything the doctor may have to supply for you including inhalers, dressings and
appliances. Please include details of doses.
NOTE: IF YOU ARE ON REPEAT MEDICATION, YOU MUST MAKE AN APPOINTMENT TO SEE A GP
MEDICATION
DOSE
(ie 20mg tabs)
TIMES
PER DAY
PLEASE NOTE: This is not an order form for medications. Please ensure that you place an order for
any repeats in good time in the normal way.
PLEASE HELP US BY COMPLETING THE FOLLOWING HEALTH INFORMATION
BLOOD PRESSURE
Sys
Dia
Pulse
SMOKING STATUS
PLEASE NOTE – The practice offers a stop smoking
service. If you would like information on this, please
ask a receptionist
Circle as appropriate:
Never smoked
Cigarette smoker
………per day
Cigar smoker
………per day
Pipe smoker
.…….. oz/day
Ex-smoker
Date stopped…………….
.
WEIGHT
…….. kilos
HEIGHT
…….. feet
…….. inches
…….. metres
ALCOHOL INTAKE – Units per week
1 unit = 1 small glass of wine
Half pint of beer
URINE
…….. stones
…….. pounds
…………. Units per week
Glucose:
Protein:
Other:
ALLERGIES
Please list any significant allergies (ie penicillin / other
drugs) and tell us the nature of the reaction (ie rash /
nausea)
Date of last immunisation (if known):
Influenza ………………………………………………
Pneumococcal ……………………………………………
ANY OTHER IMPORTANT INFORMATION NOT INCLUDED ABOVE
I AM ENTITLED TO NHS SERVICES AS I HAVE BEEN OR INTEND TO BE RESIDENT IN THE UK FOR A
PERIOD OF SIX MONTHS OR LONGER.
Signature of patient or agent .……………………………………………….
Date…………………………………….
ETHNIC GROUP
Please circle as appropriate
White
Asian / Asian
British
Black / Black
British
Mixed
Other
British
Indian
Caribbean
White and Black
Caribbean
Chinese
Irish
Pakistani
African
White and Black
African
Other
Other
Bangladeshi
Other
White and Asian
Other
Other
First Language spoken:…………………………………………………………………………..
FOR SURGERY USE ONLY
Form accepted & checked by: ………………………………………..
Details of any appointments made:………………………………..
Patient registered on E-mis by: ………………………………………