NORTH ROAD SURGERY

77 North Road, Kew, Surrey. TW9 4HQ

Tel: 02088764442. Fax: 02083922311

DR. WARWICK BEALES: G9001787
DR. ALEXANDRA STRACHAN: G8137566 / DR JYOTSNA MAGAPU:G9240273

ADULT(From 15 years of age)

Welcome to North RoadSurgery.

Please note:You will only be able to make an appointment with the Practice Nurse, Health Care Assistant or Doctor after five working days from receipt of this form.

Surname:……………………………………………………...... Mr/Mrs/Miss/Ms/Dr/Other…….....…

Forename(s): ………………………………..………Status:Single/Married/Separated/Divorced/Widowed

Ethnic Origin: Please tick one of the following:

A / White British / K / Bangladeshi (Asian or Asian British)
B / White Irish / L / Any other Asian background (Asian or Asian British)
C / Any other White background / M / Caribbean (Black or Black British)
D / Mixed White and Black Caribbean / N / African (Black or Black British)
E / Mixed White and Black African / P / Any other Black background (Black or BlackBritish)
F / Mixed White and Asian / R / Chinese
G / Any other mixed background / S / Any other ethnic category
H / Indian (Asian or Asian British) / Z / Not stated
J / Pakistani (Asian or Asian British)

First Language: ...... …………………………………………………………………………………………....

Please register me for online services(Appointments, prescription requests): Yes No

E-mail Address:…………………………………………………………………………………….

Mobile telephone number:………………………………………………………………………….

What serious illnesses have you had? Please list any past and current medical problems andoperations:

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

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

Are you allergic to any medications? Please list ……………………..…………………………………

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

Please list any tablets, medicines or other treatments you are taking (including those bought over the counter):

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

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

Are there any serious illnesses which affect members of your family? ……………………………………

Continued over

When was your last tetanus immunisation? ………………………………………………………………..

Please list any other recent immunisations, e.g. Typhoid/hepatitis ………………………………………...

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

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

Are you a current smoker? YES/NOIf yes, how many per day?......

We strongly advise you to stop smoking and can help you do this. Please enquire at the practice for details.

Have you ever smoked? YES/NOWhen did you stop smoking: ……………………….…

Do you drink alcohol? YES/NOHow much/day? ……………………………………….

What sort of exercise do you take? ………………………………………………………………………….

Please describe any special diet you are following: ……………………………………………………..…..

Are you a CARER or do you HAVE A CARER(please circle applicable)

Name of the person who is cared for OR is the carer

First/Last Name______

Date of Birth____/____/______Telephone No’s ______

Address______Post Code______

To be Completed by Adult Females only

Cervical Smear ScreeningDate of last cervical smear test:______

Result of last cervical smear test: ______

Breast Screening (for over 50s)Date of last mammogram: ______

Result of last mammogram: ______

Summary Care Records have been introduced to improve the safety and quality of patient care. It enables health care providers to view your medication(last 12 months) any allergies and any adverse reactions, when you are being treated in an emergency, whilst away from home or your normal practice is closed. You automatically have a Summary Care Record if you are registered with a GP practice in England.

If you wish to opt out please ask reception how to obtain opt out form.

Patient’s signature:………………………………………………………. Date: ……………………….

NB: In order to register you must bring a photocopy and the original of the following:

  • Valid Passport
  • Utility Bill or Bank Statement (less than 3 months old).

We invite all newly registered patients to have a New Patient Health Check or NHS Health Check. Please ask reception for details.

You can help us to improve our service and have your say by joining our Patient Participation Group. We will contact you from time to time to ask for your opinion about various aspects of our service. If you would like to join, please leave your email address:

______

For practice use only: Seen - Passport /Visa

Utility Bill / Bank Statement or other