Summary Care Record Choice –
TO BE COMPLETED BY ALL NEW PATIENTS BEFORE REGISTRATION AT THIS PRACTICE
If you have any questions about Summary Care Records, please see attached ‘SCRFactsheet’ or speak to a member of staff.If you need more time to make your choice you should let your GP Practice know.
Yes I would like a Summary Care Record
No I do not want a Summary Care Record
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NEW PATIENT HEALTH QUESTIONNAIRE
Thank you for joining our practice. As we do not have your medical records yet it would be very helpful if you could complete this health questionnaire before you see the nurse or doctor. If you have a problem completing any section, please ask the nurse or doctor for help when you see them at your appointment.
THE INFORMATION YOU GIVE IS CONFIDENTIAL AND CAN ONLY BE PASSED TO OTHER PEOPLE OUTSIDE THE PRACTICE TEAM WITH YOUR CONSENT. PLEASE ASK FOR A LEAFLET ON HEALTH RECORDS FOR MORE INFO
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REGISTRATION INFORMATION:
PERSONAL DETAILS:
SURNAME:______
FORNAMES:______
TITLE:______
DATE OF BIRTH:______
ADDRESS:______
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TELEPHONE NUMBER 0207 0R 0208 WHERE APPROPRIATE:
HOME NUMBER:______WORK NUMBER:______
MOBILE NUMBER ______
OCCUPATION:______
MAIN LANGUAGE SPOKEN? ______
DO U NEED AN INTERPRETER? YES OR NO? ______
MEDICAL HISTORY:
HAVE YOU EVER HAD ANY MEDICAL PROBLEMS IN THE PAST REQUIRING HOSPITAL CLINIC ATTENDANCES? SURGERY OR REPEATED VISITS TO THE DOCTOR? PLEASE LIST WITH DATES.
ARE YOU ON ANY MEDICATION/TABLETS INCLUDING THE CONTRACEPTIVE PILL? PLEASE LIST INCLUDING DOSE AND FREQUENCY
ARE YOU ALLERGIC TO ANY MEDICINES SUCH AS PENICILLIN, DUST, HAYFEVER, ANIMALS ETC. PLEASE LIST
FAMILY HISTORY – IS THERE ANY FAMILY MEMBER WITH HISTORY OF?
DIABETES YES OR NO? IF YES WHICH FAMILY MEMBER? ______
HYPERYTENSION(HIGH BLOOD PRESSURE)YES OR NO? IF YES WHICH FAMILY MEMBER? ______
HEART ATTACKS, ANGINA ETC IF YES OR NO? IF YES WHICH FAMILY MEMBER? ______
STROKE (CVA) YES OR NO? IF YES WHICH FAMILY MEMBER? ______
ASTHMA/ALLERGIES YES OR NO? IF YES WHICH FAMILY MEMBER? ______
ANY CANCERS YES OR NO? IF YES, WHICH CANCER AND WHICH FAMILY MEMBER? ______
HEALTH DATA:
DO YOU TAKE REGULAR EXERCISE (AT LEAST 3 TIMES WEEKLY FOR 20 MINS?
YES OR NO? ______
DO YOU SMOKE? YES OR NO? ______
CIGARETTES? YES OR NO? ______ROLL UPS YES OR NO? ______
OTHER YES OR NO? ______
HOW MANY CIGARETTES? 0-10 DAILY ______11-20 DAILY ______20+DAILY ______
IF OTHER PLEASE GIVE DETAILS: ______
WOULD YOU LIKE TO GIVE UP SMOKING YES OR NO? ______
ON AVERAGE HOW MANY DAYS A WEEK DO YOU DRINK? ______
HOW MANY DRINKS PER DAY? PINTS ______GLASSES ______WINE/SPIRITS ______
DO YOU EAT A VARIED DIET? IF NOT OR IF YOU ARE ON A SPECIAL DIET PLEASE GIVE DETAILS WRITE YES OR NO.
VARIED DIET ______VEGAN DIET ______VEGETARIAN ______LOW FAT DIET ______
LOW SALT ______OTHER- PLEASE GIVE DETAILS ______
WHEN WAS YOUR LAST BOOSTER GIVEN FOR TETANUS ______POLIO ______
FOR WOMEN ONLY:
HAVE YOU EVER HAD ANY PREGNANCIES? IF SO WHEN?
WHEN WAS YOUR LAST CERVICAL SMEAR? ______
WAS IT NORMAL? YES OR NO? ______IF DONE ABROAD PLEASE PROVIDE US WITH A COPY
HAVE YOU HAD ANY ABNORMAL SMEAR RESULTS IN THE LAST 5 YEARS? YES OR NO? IF YES PLEASE GIVE DATES AND DETAILS OF ANY TREATMENT YOU HAVE HADAND PROVIDE COPIES PROOF ______
WHEN WAS YOUR LAST MAMMOGRAM? WAS IT NORMAL YES OR NO? PLEASE GIVE DETAILS OF ANY TREATMENT YOU HAVE HAD
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PATIENT PROFILING
This Practice, in line with other healthcare providers and all other statutory services is now collecting profiling information about our patients, which includes ethnicity. This information will help us learn more about the health needs of our local community and allow us to plan services to meet those health needs competently.
All information we receive will be used and treated with the strictest of confidence.
If you have any queries about completing this form please ask a member of staff. Otherwise please complete the form below and pleaseTICK which of the ethnic group you feel you belong to. Thank you.
PATIENT NAME: ______
DATE OF BIRTH: ______
WHITE BRITISH ______
WHITE IRISH ______
OTHER WHITE ______
WHITE/BLACK CARRIBBEAN ______
WHITE/BLACK AFRICIAN ______
WHITE/ASIAN ______
OTHER MIXED______
INDIAN ______
PAKISTANI ______
BANGLADESHI ______
OTHER ASIAN ______
BLACK OR BLACK BRITISH ______
BLACK CARRIBEAN ______
AFRICIAN ______
OTHER BLACK ______
CHINESE OR OTHER ETHNIC GROUP ______
OTHER:
The Fast Alcohol Screening Test (FAST)
QUESTIONS / SCORING SCHEME0 1 2 3 4 / ENTER SCORE BELOW:
- How often do you have 8 (for men) or 6 (for women) or more drinks on one occasion?
Only consider questions 2, 3, and 4 if the response to question 1 is less than or equal to monthly
- How often during the last year have you been unable to remember what happened the night before because you had been drinking?
- How often during the last year have you failed to do what is normally expected of you because of your drinking?
4. In the last year has a relative or friend, or a doctor or a health worker been concerned about your drinking or suggested you cut your drinking down? / No / Yes, on one occasion / Yes, on more than one occasion
Total:
Scoring:
A score of 0 on the first question indicates FAST negative
A total of 1 – 2 on the first question then continue with the next three questions.
A total of 3 – 4 on the first question stop screening at first question.
An overall total score of 3 or above is FAST positive.
THE NEXT SECTION IS ONLY FOR THE PRACTICE NURSE OR DOCTOR TO COMPLETE ONLY
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WEIGHT: ______HEIGHT: ______
BMI : ______BP READING: ______
URINALYSIS: PROTEIN: ______GLUCOSE ______
HEALTH PROMOTION ADVICE GIVEN YES OR NO? ______
ADVICE LEAFLETS GIVEN YES OR NO? ______
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