Download Medical Questionnaire - West Point Medical Centre

WEST POINT MEDICAL CENTRE
MEDICAL QUESTIONNAIRE & REGISTRATION FORM FOR NEW PATIENTS
(Please note: it is important to be as accurate as possible when filling out this questionnaire)
Name
Date of Birth
Address (inc. flat number)
Gender:
⃞ Male
⃞ Female
Telephone:
Postcode
Mobile No:
Marital Status:
Occupation:
Have you been registered here before? Yes / No
If you were previously registered with the Practice and have changed your Surname, please tell us
your previous Surname (your details will be already stored on our computer).
Next of kin
Name
Telephone No.
Address
Relationship to you
Are other members of your household registered/registering at the practice?
Name
Date of Birth
Please indicate your ethnic group
⃞ White Scottish
⃞ Asian - Indian
⃞ White British
⃞ Asian - Pakistani
⃞ White Irish
⃞ Asian - Bangladeshi
Other white background (please state)
⃞ Chinese
Other Asian background (please state)
⃞ Black Caribbean
⃞ Black African
Other Black background (please state)
⃞ Mixed race
Any other ethnic group (please state)
Language
What is your First Language
If your first language is not English, do you need an interpreter ?
Do you understand written English?
Yes
Yes
No
No
Medical Information
(please fill in completely)
Smoking status
I have never smoked
What is your present weight?
I am a current smoker, and smoke
less than 1 per day
1 to 9 per day
10 to 19 per day
20 to 39 per day
More than 40 per day
_________________
I am an ex-smoker and used to smoke
less than 1 per day
1 to 9 per day
10 to 19 per day
20 to 39 per day
More than 40 per day
Date stopped:
How tall are you?
Organ / Blood Donation
Please delete below as applicable
Do you wish to join the NHS Organ Donor Scheme?
Yes / No
Do you wish to join the NHS Blood Donor Scheme?
Yes / No
___________________
EXERCISE
In an average week how often do you exercise?
no regular exercise
1 to 3 twenty minute sessions per week
More than 3 twenty minute sessions per week
I am a competitive athlete
Note: Twenty minutes of vigorous walking counts as 1
exercise session.
Current Medical Problems/Illnesses/Mental health issues
Any significant health problems – if yes please give year of diagnosis:Atrial Fibrillation
Absent spleen (Asplenic)
Asthma
COPD (e.g. emphysema or chronic bronchitis)
Coronary heart disease (e.g. heart failure, myocardial infarction and angina)
Current kidney disorders
Depression
Diabetes
Epilepsy
High blood pressure
Hypothyroidism
Stroke/CVA/TIA
Any operations (Please give details)
Any significant family history - please specify
Other – please specify
Any significant medical history in blood relatives under 65 years of age
Please specify which illness and what relation the sufferer is to you.
Do You Have Any Allergies?
(Please include drug allergies and non drug allergies e.g. penicillin, peanuts, bee sting, pollen etc)
Regular Medication: Please give details of medication (including over the counter medication) that
you have been taking on a regular basis, so that we can put this on our computer for your repeat
prescriptions. This includes contraception. Please note that we will need a repeat form from your
previous GP.
Name of Drug
Dosage (if known)
Date Started
Females Only
(Please note: it is important to be as accurate as possible when filling out this questionnaire)
Are you using a mode of contraception at the moment? Yes / No If so which?
Are you pregnant at the moment: Y / N
No. of weeks?
Expected date of delivery:
Please Circle
Please give details of any miscarriage, termination or still birth:
Have you had a Hysterectomy: Y / N
Date of Operation _____________
Please Circle
Date of Last Smear: ____________(Month & Year)
Smear Result: Normal / Abnormal
Country where taken: _______________
When is your next smear due? ____________
Alcohol Screening
To be completed by all patients
FAST
Questions
How often have you had 6 or more units if
female, or 8 or more if male, on a single
occasion in the last year?
Scoring system
0
1
2
Never
Less
than
monthly
Monthly
Your
score
3
4
Weekly
Daily
or
almost
daily
Stop here if the answer is Never (0). Otherwise carry on and fill in the AUDIT
questionnaire below also.
How often during the last year have you
failed to do what was normally expected
from you because of your drinking?
How often during the last year have you
been unable to remember what happened
the night before because you had been
drinking?
Has a relative or friend, doctor or other
health worker been concerned about your
drinking or suggested that you cut down?
Never
Less
than
monthly
Never
Less
than
monthly
Monthly
Monthly
Weekly
Daily
or
almost
daily
Weekly
Daily
or
almost
daily
Yes,
but not
in the
last
year
No
Yes,
during
the
last
year
Total
AUDIT
Questions
How often do you have a drink containing
alcohol?
How many units of alcohol do you drink on a
typical day when you are drinking?
How often during the last year have you found
that you were not able to stop drinking once
you had started?
How often during the last year have you
needed an alcoholic drink in the morning to
get yourself going after a heavy drinking
session?
How often during the last year have you had a
feeling of guilt or remorse after drinking?
Have you or somebody else been injured as a
result of your drinking?
Scoring system
0
1
2
3
4
Never
Monthly
or less
2-4
times
per
month
2-3
times
per
week
4+
times
per
week
1 -2
3-4
5-6
7-8
10+
Never
Less
than
monthly
Weekly
Daily
or
almost
daily
Never
Less
than
monthly
Weekly
Daily
or
almost
daily
Never
Less
than
monthly
No
Monthly
Monthly
Monthly
Yes,
but not
in the
last
year
Weekly
Your
score
Daily
or
almost
daily
Yes,
during
the
last
year
Total
_____
We will use the contact details you have provided on this form to contact you when necessary.
When necessary we can contact patients by letter, telephone, e mail and text.
If you prefer not to be contacted by any of these methods please let us know.
Finally, to complete the registration process please sign the GMS1 form
and return everything to the practice.
Please feel free to familiarise yourself with the services we provide by reading the practice leaflet,
available in our Reception Area or by visiting our website at www.westpoint-gp.nhs.uk.
Thank you.
WELCOME TO WEST POINT MEDICAL CENTRE
(Patient’s Signature):
Date: