Wadebridge and Camel Estuary Practice

New Patient Assessment

CONFIDENTIAL MEDICAL NEW PATIENT ASSESSMENT FORM

Please complete all pages in Full using BLOCK capitals

Surname

First names (in full)

Previous surnames

Title: Mr Mrs Miss Ms Dr ……………………………………. Marital status ……………………………

Male Female

Date of birth (day/month/year)

Town and Country of Birth

CurrentAddress

Postcode:

Telephone number Mobile number:

Parents:

Mothers full name

Fathers full name

Please help us to trace your previous medical records by providing the following information:

Your previous address in the UK:

Postcode:

Name of previous Doctor

While at that address

Address of previous

Doctor

No previous address/first surgery in the UK due to:

Birth – this is my first surgery

Immigrant – please state date you entered the UK: ……………………………………………………………………

Have you ever been registered at this practice before? Yes No

Your first UK address where registered with a GP:

Postcode:

Please tell us about yourself:

Are you are carer? Yes NoDo you have a carer? Yes No

If yes, please tell us the name and address

of your carer:

Personal medical history:

Have you ever suffered from any important medical illness, operation or admission to hospital? If so, please enter details below:

Diabetes – Type 1 or 2 / Dementia
Heart disease / COPD/Emphysema
Stroke / High blood pressure
Learning disability / Thyroid problems
Asthma and currently use medication / Depression in last 12 months
Registered blind or partially sighted / Cancer
Deaf/Very hard of hearing
Do you have any special communication needs?
Yes No
If yes:
Sign language
Large print
Other ……………………………………………………………. / Take warfarin – if you take warfarin please ensure you book a blood test appointment with a phlebotomist and a doctor (for your first test) to be added to our system. Please ensure you bring your yellow book/last blood test results and dosing sheet to the appointment and tell the Receptionist you are booking a warfarin check
Any other conditions
Confirmed allergies

Ethnic origin

British or mixed British / White / White British / English / Cornish
Scottish / Welsh / Irish / Black British / Black
Polish / African / Caribbean / Indian / Pakistani
Bangladeshi / Chinese / Other (please state):
Ethnic origin refused to give

First language spoken:English / Other: Please specify: ……………………………………………

Do you need an interpreter? Yes / No - If yes please specify language: …………………………………………………..

Next of Kin:

Name: / Telephone number: / Relationship:

Lifestyle Questions

You can use the scales or blood pressure monitor in the waiting room at the Wadebridge Surgery if you aged 18 years or over

Please enter your height and weight:

Height …………………………………………………….Weight …………………………………………

Blood pressure …………………………………………………………………

Smoking

Never smoked

Current Smoker – Number of cigarettes/cigars per day: …………………………………

I would like advice on giving up.

No, I Do NOT wish to give up.

Ex- Smoker - Number of cigarettes/cigars per day: ……………………..Date stopped: ………………………………………

If you would like to give up smoking, please book an appointment with our Stop Smoking Advisor Sarah Roberts

Do you drink Alcohol?

Please estimate your alcohol intake per week (1 unit = half pint beer or 1 glass of wine or 1 measure of spirit)

Number of alcohol units per week ______

ALCOHOL AUDIT – C / 0 / 1 / 2 / 3 / 4 / Your Score
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 units if male, on a single occasion in the last year? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily

A total of 5+ indicates increasing or higher risk drinking.

An overall total score of 5 or above is AUDIT-C positive

If you would like to discuss this, please make an appointment with a doctor

Female patients only:

Are you currently, or think you may be pregnant? YesExpected due date: …………………………………………………

No

Which method of contraception (if any) are you using at present? ………………………………………………………………………………

The surgery provides a free appointment reminder service using sms text messages for patients aged over 16 years, if you wish to opt out please contact Reception and ask for “Opt out of text message” form.

At the main Surgery in Wadebridge, we use a television call system, when you arrive for your appointments please book in either using the electronic arrivee system opposite the Reception desk or if you prefer at the Reception desk. Watch the television for your name and room number.

If you are partially sighted and cannot use the television call system, please let us know.

If you have access to a computer, you can book appointments online and also order repeat prescriptions but we must have a separate email address for you. If you wish to apply for any practice online services, please ask at Reception or see website for “Online Application form”.

Please note that online access is only available for patients aged 16 years and over. Proxy access may be granted in certain circumstances.

Please do look at our Website for a wealth of information about the Surgery at

  • I confirm that the information given on this form is complete and correct to the best of my knowledge. If any of my contact details change I understand it is my responsibility to contact the Surgery as soon as this change takes place.
  • I understand that it is my responsibility to keep any log in details safe and secure and to never share them with anyone.
  • If I have opted not to provide ID to the practice I take full responsibility should any unauthorised access occur.
  • I have fully read and understand this application form

PLEASE ONLY TICK IF YOU DECLINE TO PROVIDE ID:

I decline to provide ID to the practice and take full responsibility should any unauthorised access occur.

Signed:

Date:

OFFICE USE ONLY: (Reception - You must sign and date at least one of the following):

Photographic ID seen / Copy in notes / Seen by: / Date:
Birth certificate / Copy in notes / Seen by / Date:
Marriage certificate / Copy in notes / Seen by: / Date:
Utility Bill / Copy in notes / Seen by: / Date:
Bank/Credit Card Statement / Copy in notes / Seen by: / Date:
Refused to give ID / Seen by: / Date:

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W:\FORMS\New patient form updated July 2016.doc