Dr M. A. Khan Thephoenix Medical Practice1a Cavendish Court

Dr M. A. Khan ThePhoenix Medical Practice1a Cavendish Court

South Parade

Tel: 01302 323992 Fax: 01302 760568 Doncaster

Website:phoenixmedicalpractice.nhs.uk DN1 2DJ

PATIENT REGISTRATION QUESTIONNAIREDATE: ………………………

Please answerALLquestions or as many as you can. The information will help us to provide you with good medical care until your medical records arrive from your previous GP. Please PRINTall answers in BLOCK CAPITALS. Please note that photographic ID and proof of address is required for all registrations.

Surname: ……………………………………….. Forename: ……………………………………………

Maiden Name:…………………………………... Date of Birth: …………………………………………

Title: Mr/Mrs/Miss/Ms: …………………………. Place of Birth: ……………………………………………..

Sex: MALE/FEMALE Date of UK entry if not born in UK: ……………………

Present Address: ……………………………… Telephone Number: ………………………………………

……………………………………………………... Mobile Number: ……………………………………......

……………………………………………………… E-mail address: …………………………………………..

……………………………………………………... NHS No: (if known) ……………………………………….

Postcode: …..…………………………………… Ethnic Origin: ……………………………………………..

Previous Address (uk only): ………………… Main Spoken Language: ………………………......

………………………………………………………. Previous GP Practice: …………………………………..

………………………………………………………. Reason for leaving: ……………………………………...

If Patient is a child under 18 please complete this section in CAPITAL LETTERS:
Name of Parent/guardian:
Relationship to Child:
Name of School:

Occupation: ………………………………………

Are you?:SingleMarriedSeparatedDivorcedWidowedCivil Partnership

Next of Kin(to contact in an emergency): …………………………………………………………………………………

Relationship to you: …………………………………… Tel No:………………………………………………..

Personal Health History

Do you suffer from any of the following illnesses? Please tick all that apply

Asthma / Nervous Disorders
Eczema / Diabetes
Skin Disease / Heart Disorders
Epilepsy or Fits / High Blood Pressure
Stroke / Chronic Bronchitis
Pneumoconiosis / Kidney Disease
Cancer

Have you had any serious illnesses or operations?

If yes please give details and dates……………………………………………………………………………

……………………………………………………………………………………………………………………..

Are you taking any regular medication? If yes, please give details. ……………......

………………………………………………………………………………………………………………………

Do you have any allergies? Please give details. ………………………………………………………………

………………………………………………………………………………………………………………………

Are you either a carer for a family member who is sick, disabled or elderly or are you being care for by someone? If yes, please give details……………………………………………………………………………

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FOR WOMEN

Have you ever had a cervical smear? YES/NO If yes, please give date of last smear …………………

Are you on the contraceptive pill? YES/NO If yes, for how long? ……………………………………

Do you have a coil fitted? YES/NO If yes, how long have you had it? ……………………

IMMUNISATIONS

Did you have your childhood immunisations?ALL/SOME/NONE

When was your last immunisation against TETANUS/POLIO, please give details below.

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YOUR HEALTH

Are you currently in good health?YES/NO

Do you smoke?YES/NO

If yes what do you smoke?CIGARETTES/ROLL YOUR OWN/PIPE

How much do you smoke a day?……………………………………………..

If you don’t smoke have you ever smoked?YES/NO

If you do smoke would you ever considered stopping? YES/NO

If you would like help to stop smoking we can direct you to Doncaster & Rotherham SmokeFree Services our local stop smoking service, you can contact them on 0800 6120011 or ask the receptionist for more details.

HOW MUCH ALCOHOL DO YOU DRINK?

Question/Scoring
System / 0 / 1 / 2 / 3 / 4 / YOUR SCORE
1. How often do you have a drink that contains alcohol? / Never / Monthly or less / 2-4 times per month / 2-3 times per week / 4+ times per week
2. How many standard alcoholic drinks do you have on a typical day when you are drinking? / 1-2 / 3-4 / 5-6 / 7-9 / 10+
3. How often do you have 6 or more standard drinks on one occasion? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
Total score:

Do you take regular exercise?YES/NO

If yes, what do you do for exercise and how often? …………………………………………………………..

……………………………………………………………………………………………………………………….

YOUR FAMILY HISTORY

Is there any significant family history we need to be aware of? If yes, please give details below

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Before the age of 60 years have either or your parents or any brothers or sisters suffered from:

a) Angina YES/NORelative: ……………………………………………

b)Heart AttackYES/NORelative: ……………………………………………

c)StrokeYES/NORelative: ……………………………………………

All of the information given will be added to your medical records.

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Summary Care Record (SCR)

When you register at this practice you will automatically have a Summary Care Record. A Summary Care Record contains important information about any medicines you are taking and allergies. Giving Healthcare staff access to this information can prevent mistakes being made when caring for you in an emergency or when you GP practice is closed. Your Summary Care Record will include your name, address, date of birth, your unique NHS number to help correctly identify you, allergies and medications you are taking.

Are you happy to have a Summary Care Record YES/NO

If you are not happy to have an SCR please ask the Receptionist for an exemption form

SMS Messaging

This surgery sends text messages for the purposes of health promotion and appointment reminders. If you DO NOT wish to receive these messages please tick the box below otherwise you will receive these messages automatically. Please note that it is your responsibility to remember appointments at the practice and not receiving a text message is not a reason to miss appointments. It is a free service but sometimes due to technical failure we cannot 100% guarantee you will receive them on all occasions.

□I DO NOT consent to the practice contacting me by text message.

Please note that all patients (aged over 9 years) will require a new patient medical. An appointment will be sent to you once your registration has been processed.

Patient Signature: ………………………………………………

1March 2017