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Dr Andrea Trill Dr Katherine Govier Mrs Kathryn Kyle
Welcome to Exmoor Medical Centre
We would be grateful if you would complete this short questionnaire. This information, which is confidential, will go onto your computer medical records to assist the medical team.
From April 2014 all practices are required to provide all their patients aged over 75 with a named GP. If you are aged over 75 Dr Trill will be your named GP, this does not prevent you from seeing any GP in the practice,it means that Dr Trill has overall responsibility for the care and support that our surgery provides to you.
CONFIDENTIALITY
The Data Protection Act prohibits the disclosure of personal information to anyone other than the patient and the Health Authority.
Title:...... Surname: ...... … Forenames: ………..………………………
Date of Birth: ...... Marital Status:…………………………..….
Address: ......
Postcode: ......
Telephone No: Home ……………………..Mobile: ...... Work: ……………………
No permanent address.
Email: ......
Occupation (if retired please give previous): ......
EMERGENCY CONTACT DETAILS:
Name: ...... Address:...... ….Postcode......
Telephone No: ...... Relationship to you: ......
NATIONALITY please indicate White British etc...... Indicate first language if not English ......
White British Irish Scottish Welsh
Other White Please state ……………..…W & B CaribbeanW & B African
White & Asian Other Mixed Indian I British Pakistani I British
Other Asian Caribbean AfricanOther Black
Chinese Nationality withheld Other:......
Do you have a carer?Yes No
Name of Carer……………………………………….. Telephone No of Carer …………………..
Relationship to you ………………………………………
Are you a carer?Yes No
Please give the name and telephone no of the person you care for if they are registered with us.
Name of person cared for ……………………………………….. Telephone No …………………..
Relationship to you ………………………………………
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Own Medical History (with datesif possible)
Operations ......
Other hospital Admissions ………......
Stroke ......
Heart disease......
Diabetes ......
High blood pressure ......
Asthma ......
COPD (bronchitis/emphysema)…......
Cancer......
TBHepatitis/other serious infection......
Epilepsy......
Mental health problems ......
Arthritis......
Back pain......
Kidney disease......
Thyroid problems…………………………………
Other......
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Family history of parents, brother or sister.Family member(s) / Age diagnosed (if known) / (age at death)
Diabetes
Heart disease
High Blood Pressure
Stroke
Epilepsy
Cancer (specify)
Asthma
COPD (bronchitis/emphysema)
Glaucoma
Thyroid problems
Other / …………………………….
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MEDICATION
If you take regular medications, please make a routine appointment with one of the Doctors to discuss this and arrange your repeat prescriptions.
Allergies: (Please describe drug and reaction)
Drug Allergy: ……………………………………………….
Other Allergies: (eg pets/pollens/foods etc) ……………..……..
LIFESTYLE QUESTIONS
For patients aged 15 and over:
Smoking (Please answer relevant boxes)Never Smoked
Ex- smoker / Date you stopped smoking: / How many did you smoke a day? / For how long did you smoke?
Current Smoker / How many do you smoke a day? / Do you smoke cigarettes, roll-ups, cigars, or pipe / Would you like help to stop smoking?
If you would like some advice to help you stop smoking, please make an appointment for smoking cessation with Andrea Phillips our Health Care Assistant.
ALCOHOL:
PLEASE ALSO COMPLETE THE ATTACHED QUESTIONNAIRE
How many units per week do you drink? …………………………
(1 unit = small glass wine or 1 measure of spirits or ½ pint normal strength beer/lager, stronger beers may be 2-7 units per ½ pint)
Height: …………………………..Weight: ……………………………..
Females only:
Please give the date and result of your last cervical smear test: ………………………………………………….
Have you had a mammogram:Yes No
If yes please give last date and result: ……………………………………………………………
Current contraception (please circle type of contraception used)
Combined pill – Progesterone only pill (mini-pill) – injection – implant – IUD (Coil) or IUS (Mirena)
Please give date of IUD insertion or date of last injection.
THANK YOU FOR YOUR TIME,
PLEASE HAND THIS QUESTIONNAIRE TO THE RECEPTIONIST
OR POST IT TO THE SURGERY.
Signed ………………………………………………………..Date …………………………………….
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.
Score from AUDIT- C (other side)
Remaining AUDIT questions
Questions / Scoring system / Your score0 / 1 / 2 / 3 / 4
How often during the last 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 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 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, but not in the last year / Yes, during 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, but not in the last year / Yes, during the last year
Scoring: 0 – 7 Lower risk, 8 – 15 Increasing risk,
16 – 19 Higher risk, 20+ Possible dependence
TOTAL Score equals
AUDIT C Score (above) +
Score of remaining questions
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