Anchor Mill Medical Practice

New Patient Details

Name ____________________________ Date of Birth ____________________

Address __________________________ Tel. No. _________________________

___________________________ Height (cm)_____________________

Weight (kg)______________________

Other Occupants with

relationship and ages ________________

___________________________________

___________________________________ Urinalysis _______________________

What Exercise do you take?

Occupation ________________________ ________________________________

Any Significant Disability ___________ Smoker/ Non Smoker/ Never Smoked

__________________________________

No. per day _____________________

Medical History and Operations (with dates)

______________________________________ If Ex-smoker, date stopped ________

______________________________________

______________________________________

______________________________________

______________________________________ Alcohol Intake/week ______________

Present Medication _____________________

______________________________________ Pregnancy History _______________

______________________________________ ________________________________

______________________________________

______________________________________

______________________________________ Date of Last Cervical Smear _______

Done by GP YES NO

If no, where _____________________

Allergies/Drug Reactions _________________

Next Smear Due _________________

Known family illnesses, ie Diabetes, Epilepsy, Language Spoken ________________

High BP, Heart Disease, Stroke, Cancer

_______________________________________ Do you require an interpreter? _____ _______________________________________

_______________________________________ Next of Kin _____________________

_______________________________________

Carer Details ____________________

________________________________

_______________________________

Ethnic Origin

Please select your ethnic origin group by choosing from one of the categories.

A. White ¨ Scottish (9S13)

¨ Other British (9S14)

¨ Irish (9S11)

Any other white background (9S12) _____________________

B Mixed Any mixed background (9SB) __________________________

C Asian, Asian Scottish, Asian British

¨ Indian (9S6)

¨ Pakistani (9S7)

¨ Bangladeshi (9S8)

¨ Chinese (9S9)

Any other Asian background (9SH) ______________________

D Black ¨ British (9S41)

¨ Caribbean (9S2)

¨ African (9S3)

Any other Black background (9SG) ______________________

E Other Ethnic Group ¨ Please specify ______________________________