The Bush Doctors Surgery Patient Health Questionnaire

Please complete All questions on this form. If you need assistance with this form please ask a member of staff.

Personal Details

Full Name:

Date of Birth:

Sex:

Occupation:

Telephone (home):

Telephone (work):

Mobile:

Email Address:

Next of Kin: Relationship: Tel:

Country of Origin:

Are you a refugee or are you seeking political asylum in the U.K.? Yes/No

Are you an entrant to the UK in the last 5 years? Yes/No

Were you born or have you lived or worked for more than one month in a country recognised as a high risk for Tuberculosis? Yes/No

(High risk for Tuberculosis (TB) is everywhere except Canada/ USA/ Northern Europe/Australia/ New Zealand).

______

*Main Language Spoken:

*Do you require an interpreter Yes/ No

*Please indicate your ethnic origin using the back page of this form.

Write the alphabet letter that appears beside your ethnic group in the space above

______

*Are you a Carer? Yes/ No Do you have a Carer? Yes/No

If you answered “yes” please ask for If yes please provide the contact

a leaflet at reception details of your Carer

Name:

Telephone No:

______

If you are registering a child under 16 please can you provide their school details;

Childs name:

School:

Address:

Telephone No:

______

Lifestyle

What is your height?What is your weight?

*Do you smoke? Yes/NoIf yes, how many a day:

If no have you ever smoked? Yes/No

If yes how many did you smoke

*Do you drink alcohol? Yes/No If so how many units per week do you consume:

e.g 1 glass of wine= 1 unit1 half a pint= 1 unit 1 measure of spirit= 1 unit

Do you exercise at least 3 times a week Yes/No

Are you allergic to any drugs or medicines Yes/ No

Medical History

Please give details of any previous major illnesses, medical problems and operations with dates:

…..…………………………………………………………………………………..……………………………………………………………………………………….If you are taking any regular medication please state name and dose:

………………………………………………………………………………………

If you are taking regular medication please make an appointment to see a GP as prescriptions will not be issued if you have not seen a GP at the practice.

Have you had any vaccinations within the last 10 years? Please state and include childhood immunisations:

…………………………………………………….Date:

Do you, or have you suffered with any of these illnesses?

Asthma / Yes / No / Diabetes / Yes / No
Angina / Yes / No / Epilepsy / Yes / No
Cancer / Yes / No / Highblood pressure / Yes / No
Stroke / Yes / No / Mental Illness / Yes / No
Chronis Kidney Disease(stages 3-5) / Yes / No / Transient Ischaemic Attack (TIA) / Yes / No
Atrial Fibrillation / Yes / No / Heart Failure / Yes / No
Peripheral Arterial Disease (PAD) / Yes / No / Familial Hypercholesterolaemia / Yes / No
Coronary Heart Disease / Yes / No

Family History

Please state any significant family medical history, e.g. heart disease

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

______

Well Woman

Are you using any contraception? If so please specify

Please note you will need to see a GP/nurse before any prescriptions will be issued)

*Have you had a smear Yes/ No

Date of test:

Result:

Place of procedure:

IfABROAD please state which country

Name of doctor/clinic:

What was the result?

When is your next test due?3 years12 months6 months

(Please Circle)

Do you have a copy/ letter stating the result?

Have you had an abnormal smear?

Have you ever had a Hysterectomy? Yes/ No

If “yes” when and where?

Was it a Total Hysterectomy? Yes/ No

______

We appreciate the time you have taken to complete this form. The information you have provided will be valuable in assessing any health needs that you may have. If you have any queries about this form, please contact the Practice Manager.

Name……………………… Signature………………………. Date…………….

______

NB: The Hammersmith and Fulham PCT recognises that informal carers provide an invaluable service and in partnership with the LBHF they are keen to ensure that carers are provided with all the support and information available to help them. To this effect, please state if you are an informal carer of if you have a carer, if yes, then please provide carers name……………………………………………………..

Patient records are held on the computer as well as paper. GP’s are responsible for the confidentiality of these records. On occasion, we share information from the patient records with the Heath Authority, the local Primary Care Group/ Trust, hospitals and other NHS/ partner organisations in the interests of patient care.

I agree to my medical records being held under the above terms and I certify that the information I have provided is correct to the best of my knowledge.

Name……………………… Signature………………………. Date……………

Recording of Ethnic Group Information for Patients

This practice, in line with other healthcare providers, collects information about the ethnic group of patients. This information can help us plan to meet the needs of the community and ensure that everyone has equal access to the healthcare we provide.

Please note that we are not asking about citizenship or nationality, but about the ethnic group which you feel you belong to.

All the information we receive will be used and treated with the strictest confidence. Any planning information on general release will be anonymous with all names removed.

The classification is entirely voluntary but will help us to provide a better service. The level of care you will be offered at this practice will not be affected by decision to complete this form.

If you have any queries about completing this form please ask a member of staff. Otherwise use this as a guide to fill in the questionnaire. If you feel you are descended from more than one ethnic group, please select the one that you feel you most belong to or chose the ‘Any other ethnic group’ and specify the ethnic groups

Many thanks

White British/ Mixed
WhiteIrish
White Any other background
Mixed White and Black Caribbean
Mixed White and Black African
Mixed White and Asian
Mixed Any other mixed background
Indian or Indian British
Pakistani or Pakistani British
Bangladeshi or Bangladeshi British
Other Asian
Caribbean
African
Chinese
Any other black background
Indian
Refused/ Not stated

The Bush Doctors Surgery Registration Policy

All non NHS services will incur charges depending upon the services requested. The current fees are available from reception upon request.

If you change your address, or telephone number please let us know as important correspondence from our Practice may be missed.

Please note that for the first seven days of your sickness a private sick certificate can be issued but will incur a charge.

Request for repeat medications are not accepted over the phone. Please use a stamped addressed envelope or come in to the surgery in person. 48 hours notice is required for this service.

To speak to the Doctor please ring before 12.30pm and leave a message for the doctor to call you back. All non urgent calls received after 12.30pm will not be dealt with until the following day.

RUDENESS AND AGGRESSIVE BEHAVIOUR WILL NOT BE TOLERATED AND WILL RESULT IN INSTANT REMOVAL FROM THE DOCTORS LIST

I (please insert your name)……………………………………………………………….

of (please insert address)…………………………………………………………………

agree to comply with the above conditions of my registration at The Bush Doctors Surgery

Patient signature………………………………… Date………………………….

AUDIT C

Questions / Your Score
Scoring System / 0 / 1 / 2 / 3 / 4
How often do you have a drink containing alcohol? / Never / Monthly or less / 2-4 times per month / 2-3 times per week / 4+ times per week
How many units of alcohol do you drink on a typical day when you are drinking? / 1-2 / 3-4 / 5-6 / 7-9 / 10+
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily

Scoring:

A total of 5+ indicates increasing or higher risk drinking

An overall total score of 5 or above is AUDIT C positive

Brief Advice Tool

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