Adelaide Medical Centre - Patient Information Form
Adelaide Medical Centre - Patient Information Form
Please ensure you complete all sections of this form
Personal & Contact Details
Title:(Mr/Mrs/Ms/Miss/Other)………………………………… Date of Birth:…………/…………./……………
Surname: ………………………………………………………………… First Name:…………………………………………
Calling/Preferred Name:………………………………………….. Address:…………………………………………….
……………………………………………………………………………………………………………………………………………..
…………………………………… Postcode: …………………Home Telephone:…………………………………......
Mobile No:……………………………………………...Email:…………………………………………………………………..
Communication Support
Do you need an interpreter? Yes [ ]No [ ] Language:…………………………………………………..
(Note: if you have any more detailed communication needs, or are a carer, please complete the section at the back of this form)
Ethnicity
White: Black or Black British:
British [ ]Caribbean [ ]
Irish [ ]African [ ]
Other White Background: ………………………… Other Black Background:………………………………….
Asian or Asian British:Mixed:
Indian [ ]White & Black Caribbean [ ]
Pakistani [ ]White & Black African [ ]
Bangladeshi [ ]White & Asian [ ]
Other Asian Background:………………………….. Other Mixed Background:………………………………..
Chinese [ ]Other Ethnic Group:…………………………………………
Next of Kin (for contact in case of emergency)
Full Name:……………………………………………………......
Telephone Number:……………………………………………..Relationship To You:……………………………….
Audit – C: Please complete the following questions
This is one unit of alcohol…
…and each of these is more than one unit
AUDIT – C
Questions / Scoring system / Your score0 / 1 / 2 / 3 / 4
How often do you have a drink containing alcohol? / Never / Monthly
or less / 2 - 4 times per month / 2 - 3 times per week / 4+ times per week
How many units of alcohol do you drink on a typical day when you are drinking? / 1 -2 / 3 - 4 / 5 - 6 / 7 - 9 / 10+
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? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
Scoring:
A total of 5+ indicates increasing or higher risk drinking.
An overall total score of 5 or above is AUDIT-C positive.
FAMILY HISTORY:
Is there a familyhistory of / Yes/No / Family Member(s) / Age of when first diagnosed
Heart attack
Or bypass surgery
High blood pressure
CVA/Stroke
Diabetes :
Please Specify
Type 1 [ ]
Type 2 [ ]
Asthma/COPD
Cancer:
If yes to cancer please give details of where the cancer site was.
Other:
CERVICAL CYTOLOGY (SMEAR) STATUS
Date of last cervical smear: / Repeat in: / Date:
Result (e.g. Normal, Abnormal): / Hysterectomy:
(YES/NO) / Date:
Patients arriving from overseas are asked to bring a copy of their smear result taken abroad. Please enclose a copy if you are returning this form back in the post.
ARE YOU PREGNANT?(Please circle an answer) / YES / NO
ADDITIONAL INFORMATION
SEXUAL ORENTATION: …………………………………………………………………………….
(Information is collected for National Statistics)
ALLERGIES:……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………………………
OPERATIONS: (Please can you give dates, if possible)………………………………………………………………………………………………..………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
ILLNESESS: (Please can you give dates, if possible)………………………………………………………………………………………………...……………………………………………………………………………………………………………...……………………………………………………………………………………………………………..………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Please note: The information you give will be treated confidentially and is subject to the Data Protection Act.
ADELAIDE MEDICAL CENTRE
111 ADELAIDE ROAD
LONDON
NW3 3RY
TEL: 0207 722 4135
FAX: 0207 586 7558
To be completed if you have specific communication needs
Communication Support
If you struggle to complete this form, please ask a member of staff to help you.
Do you consent for this information to be shared with other health & social care organisations? Yes [ ] No [ ]
Do you need an interpreter? Yes [ ] No [ ] Language:…………………………………………
Are you visual Impaired?Yes [ ] No [ ]
Would you benefit from any of the following: Braille [ ] Large Print [ ] Audio tape [ ]
(Please note that our system does not allow this at present, however, capturing the information will help us plan future developments)
Deafness: Yes [ ] No [ ] Other…………………………………………………………………………………
If you have a difficulty communicating, which is your preferred method of communication?
Home Tel number[ ]Letter to home address[ ]
Work Tel number[ ]Letter to temporary address[ ]
Mobile Tel number[ ]Fax[ ]
Email Address[ ]Video Conference*[ ]
(*Please note that our system doesn’t allow this at present, however, capturing the information will help us plan future developments)
Do you have any other communication need we should know about? Please Describe?Carer Information
(i) Are you a carer for someone? (Y/N) If yes, are they registered at this practice? (Y/N)
Name of the person you care for…………………………………Their contact number…………………….
(ii) Do you have a carer? (Y/N) If yes, are they registered at this practice? (Y/N)
Name of the person that takes care of you……………………………………………..
Their contact number…………………………………………………………………………
Please ask for a Carers Pack from reception
Name………………………………….………………………………… Date of Birth:…………/…………./……………
Please note: The information you give will be treated confidentially and is subject to the Data Protection Act.