The Whalebridge Practice

The Whalebridge Practice New Patient Registration Form (over 16s) About You

Mr Miss Mrs Ms Other (please state)______

Surname/Family Name: ______

First Name: ______Date of Birth: ______Age: ______

Address: ______

______Post Code: ______

Telephone: Home: ______Work: ______Mobile: ______

Please note the Practice uses a text reminder service for appointments. If you wish to opt out of this please tick the box

E-mail address: ______First Language: ______

Ethnic Origin: ______If you do not wish to inform us of this please tick

Have you ever served in the UK Armed Forces YES/NO Your Medical History Do you suffer from any of the following: (please tick all that apply and include date of diagnosis)

Diabetes Type 1 or 2 (please circle) ______Asthma ______

Heart Disease ______High Blood Pressure ______Epilepsy ______

Other(please state) ______

Family History: Do any of your close family have any of the above? Yes No

If Yes: Condition: ______Relationship: ______

Do you have any disabilities? If yes, please state: ______Vaccinations

Have you had any vaccinations in the last 3 years? Yes No

If yes, please state which and date given ______Medicines

Are you currently taking any medication? Yes No

If yes, please state which: ______

Allergies: ______Special problems: ______Alcohol

Please circle the most appropriate answer. 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits MEN: How often do you have EIGHT or more drinks on one occasion? Less than Daily or almost WOMEN: How often do you have Never Monthly Weekly monthly daily SIX or more drinks on one occasion? How often during the last year have you been unable to remember what Less than Daily or almost Never Monthly Weekly happened the night before because monthly daily you had been drinking? How often during the last year have you failed to do what was normally Less than Daily or almost Never Monthly Weekly expected of you because of monthly daily drinking? In the last year has a relative or Yes, on Yes, on more friend, or a doctor or other health No one than one worker been concerned about your occasion occasion drinking or suggested you cut down? Smoking

Do you smoke: Yes (If yes, how many per day ____) Never Ex smoker

Helping Smokers To Stop A range of services is available so you can choose an approach that suits you and your lifestyle and help you become a non-smoker or smoke free. For more information and advice or to book an appointment call the NHS Swindon Stop Smoking Service on 0800 389 2229 or 01793 465513. Carers

Are you a Carer? Yes No

Would you like to be included on our Carers Register? Yes No For Women What, if any, form of contraception do you use?

Pill Coil Depo Injection Other: ______

Date of last smear: ______

Result of last smear: ______

THIS DOCUMENT DOES NOT INDICATE THAT YOU ARE REGISTERED WITH THE WHALEBRIDGE PRACTICE For Office Use Only

Form Accepted By: ______Date: ______

Registered on Computer By: ______Date: ______