PATIENT HEALTH QUESTIONNAIRE
Please complete the following questionnaire. If you have any difficulties please ask a member of staff for help. If this is not completed fully, the Practice will be unable to complete your registration.
NAME …………………………………………………. DATE OF BIRTH………………………………..ADDRESS …………………………………………….. CONTACT PHONE NO…………………………..
……………………………………………… TODAYS DATE ………………………………….
POST CODE ……………………………………
E-MAIL ADDRESS (please write clearly) ……………………………………………………………......
ETHNICITY – There may be cultural or religious differences in relation to healthcare that we should be aware of. Please circle the applicable options below:
I would describe my Ethnicity as:White Scottish Indian African
Other White British Pakistani Black Scottish or Other Black
White Irish Bangladeshi Other Asian
Other White Chinese Other (please specify) ………………….
I would describe my Religion as:
None Church of Scotland Roman Catholic
Other Christian Buddhist Hindu
Jewish Sikh Other (please specify) ……………….
Muslim
Country of Birth:
UK Other EEC Eire
Other (please specify) …………………………………………………..
Dr W Scullion Coatbridge Health Centre Dr C McColgan
Dr NS Marcuccilli 1 Centrepark Court Dr C Heron
Dr S Connolly Coatbridge Dr L Reid
Dr L Duff ML5 3AP
01236 422 311
Family History (please list any illness which runs in your family)
Have you or any of your close family members suffered from any of the following:Heart Disease / Yes/No / Relationship to you
Diabetes / Yes/No / Relationship to you
Stroke / Yes/No / Relationship to you
Asthma / Yes/No / Relationship to you
Epilepsy/Seizures/Fits – if so when was the last seizure / Yes/No / Relationship to you
Health History
Please record any significant past illnesses, accidents, operations or other hospital admissions. Where possible, please note the approximate date on which they occurred.…………………….. ………………………………………………………………..
…………………….. ………………………………………………………………..
…………………….. ………………………………………………………………..
…………………….. ………………………………………………………………..
Do you have a history of High Blood Pressure? Yes/No
Have you had a Blood Pressure check in the last 5 years? Yes/No
Please list all medication you take at present, including any medication which you buy from the chemist.
Name Dose Name Dose
………………………… ……………. ………………………. ……………….
………………………… ……………. ………………………. ……………….
………………………… ……………. ………………………. ……………….
………………………… ……………. ………………………. ……………….
Do you have any allergies? (please specify)
PLEASE PROVIDE US WITH A COPY OF YOUR PRESCRIPTION TEAR OFF SLIP. THIS CAN BE OBTAINED FROM YOUR PREVIOUS PRACTICE.
LIFESTYLE
Please tick/delete as appropriate:
Diet:
I would regard my current diet as ( ) poor ( ) good ( ) excellent
Smoking:
( ) I have never smoked
( ) I used to smoke …………. cigarettes/cigars/pipe tobacco per day but stopped in …………………………………………
( ) I currently smoke …...... cigarettes/cigars/pipe tobacco per day
( ) Would you like advice to help stop smoking?
Drinking:
( ) I am teetotal or only drink alcohol very occasionally
( ) I used to drink ……...pints of beer,…………measures of spirits …….glasses of wine per week but I stopped in …………………..
( ) I currently drink …… pints of beer …………. measures of spirits ……. glasses of wine per week.
Exercise:
I do ( ) do not ( ) take regular exercise
Height ……………………………….. Weight……………………………….
FEMALE PATIENTS ONLY
I have had a recent smear test ( ) Date: …………………………………………………….
I have never had a smear test and would like an appointment ( )
I do not want a smear test and will sign a disclaimer excluding me for 4 years ( )
I have had a hysterectomy ( ) Date: …......
My current method of contraception is ……………………………......
Carers and Being Cared For
The Practice offers support and assistance to a carer and recognises the invaluable role they take in helping those being cared for. We ask your assistance in identifying and supporting carers.
A carer is someone, irrespective of age, who provides or supervises a substantial amount of care on a regular basis. This can be for a child, partner, relative or neighbour who is unable to manage on their own, whether this is due to illness, frailty, a physical or mental disability, distress or impairment. The term “CARER” would not apply if the person is either a paid carer, a volunteer from a voluntary agency or anyone providing assistance for payment in cash or kind.
We would be grateful if you could answer the following:
Do you care for someone (as described above)? Yes/NoDo we have permission to include your name on our carers register and to undertake
periodic review of your well being and any support that you may need? Yes/No
What is your relationship with the person you care for? …………………………………………….
Is this person registered with this practice? Yes/No
Under the Data Protection Act 1998, we also need the permission of the person being
cared for before recording their name.
Could you advise us of the name and address of the person you care for:
NAME ……………………………………………………………………………………………….
ADDRESS …………………………………………………………………………………………...
Please update the Practice if your carer status changes in any way. This will allow us to maintain our records.
NOTE TO PATIENTS WISHING TO REGTISTER WITH THIS PRACTICE
REGISTRATION PROCESS
Before registering, we will ask for proof of identification and address. Forms of identification can include a utility bill dated within the last three months, a driving license, a passport or any other document from within the last three months which shows your address.
We will ask to take a photocopy of these items for your personal record and to assist Lanarkshire Health Board should they have any queries with your registration. Any documentation will be held in the strictest confidence and destroyed thereafter once you have been fully registered.
We will ask you to supply your e-mail address for the purpose of ordering repeat medication. Please write this clearly and accurately.
If you feel this system would not suit your requirements then please reconsider completing the registration process.
APPOINTMENT SYSTEM
Waverley Medical Practice operates a TRIAGE telephone system whereby a patient telephones the Practice, selects Option 6, and speaks directly with a GP. This should be done if you require an appointment with a GP or you wish a Sick Line.
Patients are placed in a queue, and the time you call will determine how long you have to wait before speaking with the GP. Several GPs answer the phones between 8.30 and 11am and 2.30 and 5pm.
You require a touch tone phone, or if you have a mobile you must ensure that you enough credit to make the call.
ECONSULT SYSTEM
The Practice is delighted to offer a new exciting service which allows our patients to access GP advice online via our Practice website www.waverleymedicalpractice.co.uk
Please see our website for further information or ask our Reception team for a leaflet on this service.
ORDERING PRESCRIPTIONS
Repeat Prescriptions:
You can register to order your prescriptions online- please come into the Practice with your email address and ID. Regular medication will be put on repeat prescription. Once this is arranged simply put your repeat slip in the box at Reception with the items required clearly marked. Your prescription will be ready for collection after48WORKING HOURS. If you are unable to call in personally at the Practice you can send your slip in by post with a stamped address envelope for the prescription to be returned to you, but please allow extra time for this.
You can organise the collection of your prescriptions with your local chemist, but you must make arrangements with the chemist to facilitate this.
You can now order your repeat prescription via our voicemail service. To order your medication using this service, please call 01236 422 311 and choose OPTION 3.
Acute Prescriptions:
If you wish to request a prescription that you have had before but it is not on repeat for you, please call the practice on 01236 422 311 and select OPTION 4to speak to the Receptionist who will process the prescription request for you.
Dr W Scullion Coatbridge Health Centre Dr C McColgan
Dr NS Marcuccilli 1 Centrepark Court Dr C Heron
Dr S Connolly Coatbridge Dr L Reid
Dr L Duff ML5 3AP
01236 422 311