King S Medical Practice New Patient Questionnaire
King’s Medical Practice
King’s Medical Centre King Edward Street Normanton
West Yorkshire WF6 2AZ Telephone 0844 8151340 Fax 0844 8151339
King’s Medical Practice New Patient Questionnaire
Welcome to King’s Medical Practice. Before we register you here we like new patients to come and see one of our practice nurses. The nurse will go through your past medical history, introduce you to the services the practice offers and point you in the right direction if you need medical attention. The nurse will check your height, weight, blood pressure and test your urine (so please remember to bring a urine sample in any sterilized container). It often takes some time for your medical records from your previous doctor to come to us and completing this form helps us to know as much information about your health before they arrive.
Current Details
Name:Date of Birth:
Current Address:
Telephone Number:
Mobile Number:
Next details of your next of kin: / Name:
Number:
E-mail address:
Personal Medical History
Have you had any of the following medical problems? (Please circle)
Arthritis – Rheum/Osteo / yes / no / Asthma / yes / noCancer / yes / no / Chronic Bronchitis / yes / no
Depression / yes / no / Diabetes / yes / no
Epilepsy / yes / no / High blood pressure / yes / no
Thyroid problems / yes / no / Stomach ulcer / yes / no
Stroke / yes / no / Glaucoma / yes / no
Heart attack or angina / yes / no / Other (Please specify):
Please list any previous operations, accidents, serious illnesses or hospital admissions:
Date / Hospital, illness and operationFamily History Do any of the following medical problems run in your family? (Please circle)
High blood pressure Diabetes Asthma Eczema Cancer Heart Disease Strokes
If so, please give any details:Allergies
Are you allergic to anything? Please list below:
Health and Lifestyle (Please circle)
Do you smoke? / No / Yes – how many?Smoking cessation advice given?
Have you ever smoked? / No / Yes
Do you take regular exercise?
How many units of alcohol do you drink per week? (1 unit = 1 small glass of wine or ½ pint of beer)
FOR WOMEN ONLY (Please circle)
What method of contraception do you use?Are you happy with this? / Yes / No / Would you like further advice? / Yes / No
If you are taking the pill, what is its name?
If you have a coil or IUD when was it fitted?
Have you had a smear test in the last 3 years? / No / Yes / When was it?
Have you had a mammogram (breast x-ray) / No / Yes / When was it?
Pregnancies Please give details of births, pregnancies, miscarriages or abortions:
Date / DetailsImmunisation
Please request a copy of your immunisation history from your current/previous GP and bring with you to the appointment.
Medication
Please bring a list to the appointment of any current repeat medication you are taking.
FAST Score For both Men and Women
FAST FOR WOMEN
FAST - WomenHow often do you have SIX or more
drinks on one occasion? / N/A / Never (0) / Less than once monthly (1)
Monthly (2) / Weekly (3) / Daily or almost daily (4)
How often during the last year had you
been unable to remember what happened
the night before? / N/A / Never (0) / Less than once monthly (1)
Monthly (2) / Weekly (3) / Daily or almost daily (4)
How often during the last year have you failed to do what was normal expected of you because of drinking? / N/A / Never (0) / Less than once monthly (1)
Monthly (2) / Weekly (3) / Daily or almost daily (4)
In the last year has a relative, friend, doctor or other health worker been concerned about your drinking or suggested you cut down? / N/A / No (0) / Yes, on one occasion (1)
Yes, one more than only one occasion (4)
Alcohol screen - FAST alcohol screening test completed / DD/MM/YY
FAST FOR MEN
FAST - MenHow often do you have EIGHT or more
drinks on one occasion? / N/A / Never (0) / Less than once monthly (1)
Monthly (2) / Weekly (3) / Daily or almost daily (4)
How often during the last year had you
been unable to remember what happened
the night before? / N/A / Never (0) / Less than once monthly (1)
Monthly (2) / Weekly (3) / Daily or almost daily (4)
How often during the last year have you failed to do what was normal expected of you because of drinking? / N/A / Never (0) / Less than once monthly (1)
Monthly (2) / Weekly (3) / Daily or almost daily (4)
In the last year has a relative, friend, doctor or other health worker been concerned about your drinking or suggested you cut down? / N/A / No (0) / Yes, on one occasion (1)
Yes, one more than only one occasion (4)
Alcohol screen - FAST alcohol screening test completed / DD/MM/YY
Your appointment is on ... / … / … at … : …
CHECKLIST: WHAT TO BRING WITH YOU FOR YOUR NEW PATIENT APPOINTMENT
1)This questionnaire, completed as much as possible
2)Urine sample
3)Medication list
4)Immunisation history
* If an interpreter is required, PLEASE ENSURE you are given a 30 minute appointment.
King’s Medical Practice
King’s Medical Centre King Edward Street Normanton
West Yorkshire WF6 2AZ Telephone 0844 8151340 Fax 0844 8151339
On-Line Services
Confidentiality
Your clinical records are stored on SystmOne computers on a strictly confidential basis. The practice is registered with the Data Protection Agency.
Access to your clinical records by practice team members (nurses, attached staff and administrative staff) is on a strictly ‘need to know’ basis. The practice takes its responsibility to keep your clinical records private and confidential extremely seriously. It is written into all our employed staffs’ contracts that it is a serious disciplinary offence to breach this confidentiality and may lead to a staff member’s dismissal.
The SystmOne computer system is a partially shared record. The doctors in the practice can see what other healthcare workers have entered onto your record e.g. district nurse visits or contacts with the out of hours service, but they can only see your full records with your explicit consent.
If you disclose sensitive information to any member of Kings Medical Practice that you strongly feel should not be shared please discuss this in your consultation to enable the doctor or nurse to take appropriate action in their record keeping.
SystmOne On-Line
It is possible to request repeat prescriptions, book some appointments (currently Saturday mornings, early mornings and late evenings) and register with the practice via our website: To register for this service you need to come to reception in person with something that proves your identity such as a bank card, utility bill, passport or drivers licence. You will be given a user name and password and then will be able to use our on-line services.
Kings Medical Practice Newsletter
If you would like to receive announcements about what is happening in the practice via email please leave tick the box below:
YesI would like to receive announcements via email about the practice
No thanks at this moment
Kings Medical Practice Blog
David Brown writes a weekly blog about what is happening in the practice. To read the blog click on:
GP Partners Dr D W Brown Dr P Mooney Dr J M Walsh Dr E A Barber
GPs Dr J Firth Dr R Hilton Dr R Harding Dr S Deeley
Practice Managing Partner Mrs C Sanderson