Registration Form

Patient Information

Title: / Mr: / ☐ / Mrs: / ☐ / Miss: / ☐ / Other:
First Name/s: / Surname:
DOB: / NHS:
Ethnicity: / First Language:
Sex: / M / ☐ / F / ☐
Address:
Postcode:
We try to make our services as accessible as possible, when you register here you will be issued with a username and password to access our ‘Patient Online’ services so you can book appointments, order repeat prescriptions and view your medical records at home.
Please input your contact details / Yes / No
Can we contact you by: / Telephone / ☐ / ☐
SMS / ☐ / ☐
Email / ☐ / ☐

In Case of Emergency

Name: / Relationship to patient: / Telephone:
Your health
Any significant health problems. Please tick all that apply / Date diagnosed (if known)
Atrial fibrillation / ☐
Asthma / ☐
COPD (e.g. emphysema or chronic bronchitis) / ☐
Coronary heart disease / ☐
Current kidney disorders / ☐
Depression / ☐
Diabetes type 1 / ☐
Diabetes type 2 / ☐
High blood pressure / ☐
Hypothyroidism / ☐
Stroke/CVA/TIA / ☐
Epilepsy / ☐
Other (please specify) / ☐
Please list any allergies:
Current height
Current weight
In an average week, how often do you exercise? / No regular Exercise / ☐
1 – 3 twenty minute sessions per week / ☐
More than 3 twenty minute sessions per week / ☐
I am a competitive athlete / ☐
What is your smoking status? / Never smoked / ☐
Current smoker / ☐ / Per day / 1-9 / 10-20 / 20-30 / 30-40
Ex-smoker / ☐ / Per day / 1-9 / 10-20 / 20-30 / 30-40
For free advice on stopping smoking please contact Leeds Smoking Service on 0800 169 4219
PLEASE NOTE: If you take medication regularly (including contraception, tablets, cream and inhalers) you will need to book an appointment with a doctor so that they can review your medication and organise future repeat prescriptions. Please bring your medication or a list of your medicine to the appointment
Female Patients
Have you ever had an abnormal smear? / Yes / ☐ / No / ☐
When is your next smear due?
Are you currently pregnant? / Yes / ☐ / No / ☐
If yes, how many weeks? (Please book an appointment with the midwife)
I confirm the information on this form is correct to the best of my knowledge / Yes / ☐ / No / ☐
Date

Thank you and welcome to Street Lane Practice

FAST Alcohol Screening Test - Please complete the details below

If you feel that you need help or advice about an alcohol related issue please make an appointment to see the doctor

Questions / Scoring system / Score
0 / 1 / 2 / 3 / 4
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
☐
Only answer the following questions if the answer above is Monthly (1) or Less than monthly (2). Stop here if the answer is Never (0), Weekly (3) or Daily (4).
How often during the last year have you failed to do what was normally expected from you because of your drinking? / Never
☐ / Less than monthly
☐ / Monthly
☐ / Weekly
☐ / Daily or almost daily
☐
How often during the last year have you been unable to remember what happened the night before because you had been drinking? / Never
☐ / Less than monthly
☐ / Monthly
☐ / Weekly
☐ / Daily or almost daily
☐
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? / No
☐ / Yes, but not in the last year
☐ / Yes, during the last year
☐

Scoring:

A score of 0 on the first question indicates FAST negative

A total of 1 – 2 on the first question then continue with the next three questions.

A total of 3 – 4 on the first question stop screening at first question.

An overall total score of 3 or above is FAST positive.

Questions / Scoring system / Score
0 / 1 / 2 / 3 / 4
'AUDIT C' alcohol screening score:
How often during the past year have you found that you were not able to stop drinking once you had started / Never
☐ / Less than monthly
☐ / Monthly
☐ / Weekly
☐ / Daily or almost daily
☐
How often during the past year have you failed to do what was normally expected of you because of drinking? / Never
☐ / Less than monthly
☐ / Monthly
☐ / Weekly
☐ / Daily or almost daily
☐
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? / Never
☐ / Less than monthly
☐ / Monthly
☐ / Weekly
☐ / Daily or almost daily
☐
How often during the last year have you had a feeling of guilt or remorse after drinking? / Never
☐ / Less than monthly
☐ / Monthly
☐ / Weekly
☐ / Daily or almost daily
☐
How often during the last year have you been unable to remember what happened the night before because you had been drinking? / Never
☐ / Less than monthly
☐ / Monthly
☐ / Weekly
☐ / Daily or almost daily
☐
Have you or somebody else been injured as a result of your drinking? / No
☐ / Yes during last year
☐ / Yes but not in the last year
☐
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? / No
☐ / Yes during last year
☐ / Yes but not in the last year
☐