NEW PATIENT INFORMATION

Welcome to LeapValley Surgery. Please answer the following questions as completely and accurately as possible. The information you provide will be added to your medical record, which will allowus to offer you appropriate care and advice.

If you have any questions about the practice, for example how our appointment system works or the services we offer, please speak to one of our reception team and they will do their best to assist you.

Surname:First Name(s):

Address:

Home Tel No: Mobile/Work No:

Marital status:DOB:

School/Nurseryattended (if applicable):

YOUR MEDICAL INFORMATION

Do you have any serious illnesses or conditions which we should know about?

Do you have any allergies to medicines or anything else?

Height:Weight*:

*If you do not know how much you weigh, please feel free to use our scales in reception or leave this question blank

How many units of alcohol do you consume each week?

(1 unit is approximately half a pint of beer. 1.5units is approximately 125ml glass of wine or a standard pub measure of spirits)

Please circle the most appropriate answer to the questions below:

Questions / Scoring system / Your score
0 / 1 / 2 / 3 / 4
How many times do you have a drink that contains alcohol? / Never / Monthly or less / 2-4 per month / 2-3 per week / 4+ per week
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 +
How often do you have 6 or more standard drinks on one occasion? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily

Our clinical team may contact you if you score more than 5 or above, as this indicates hazardous or harmful drinking

Smoking habits: (please tick the most appropriate)

Never smoked

Ex-smoker Date stopped?

Occasional Smoker

Current SmokerHow many per day?

If you do smoke, or have smoked, what would you usually smoke? (please circle those that apply)

CigarettesCigarsPipe

Would you be interested in receiving Stop Smoking Advice?YES / NO

REPEAT PRESCRIBING

Repeat prescriptions are issued ata doctor's discretion, normally for people on long-term treatment. If you require any medication which was last issued by your previous doctor, please make your requestat least one week before you run out, and provide evidence of your previous prescription and dose. We need this information to ensure your care is not compromised in any way.

If you are on any repeat medication, you are welcome to register for our online repeat prescribing ordering service. This means that in the future you can order your medication without coming to the surgery. You can either collect your prescription from the surgery within 2 working days or, alternatively, most pharmacies in the area operate their own system for collecting prescriptions from us on your behalf. Please ask your pharmacist for more details.

Would you like to sign up to order repeat prescriptions online? YES / NO

If you have selected “yes”, please return to the surgery, with photo ID, 2 weeks after you have handed in your registration documents. You will then be given the information you will require to register online.

Please note that no one else can sign up for you and patients 16 years of age and over must register on their own behalf. Teenagers between the ages of 13 and 16 wishing to sign up, or parents wanting to register a teenager, must first speak to their GP.

CARERS

If you provide help and support to a partner, relative, child, friend or neighbour who could not manage without your help due to physical or mental illness, disability, frailty or addiction, you are a carer. The surgery is working with the Carers Support Centre in South Gloucestershire to offer support to those who care for others.

The surgery maintains a carer’s register so we can improve the services we offer to carers, and be more aware of carers needs. If you would like to know more, please ask at reception for a carers registration form.

SIGNATURE

To be signed by all patients over 16 years of age

Signature: Today’s Date:

Please return this form to Reception. Thank you for your time