The Oaks Medical Centre

The Oaks Medical Centre New Patient Questionnaire

Title MR/MRS/MS/OTHER (Please specify) DOB First Name Surname Address Postcode NHS Number Landline number Mobile number Work number E-mail address

Marital Status: (Please circle) Common Law Partnership Divorced Married Single dvdlksnv;lkzdn’fnglk;ndfgblkndfgskndfglkndf’lkgndfngk’ Separated Widowed Your Occupation:

Is anyone living at your address already registered at The Oaks Medical Centre? (Please circle) YES NO Have you ever been registered with this surgery before? (Please circle) YES NO To opt out of the Virtual Patient Participation Group (PPG) put a tick this box [ ]

Next of Kin Contact Number MR/MRS/MS/OTHER (Please Specify) First Name Relationship Surname Address

If the patient registering is under 18 years old, please give us name and contact number of parents/guardians. Mother Contact Number Father Contact Number Local School/Nursery attended

Are you a carer? (Please circle) YES NO Do you have a carer? (Please circle) YES NO Is the person you care for a (Please circle) Carers name Relative Friend Neighbour Other If Other Please specify Carers contact number Is the person who cares for you a (Please circle) Relative Friend Neighbour Other If Other Please specify

Do you suffer from any of the following? (Please circle/Give details if necessary) Asthma Epilepsy Diabetes Stroke TB Heart attack Heart Problem Cancer Depression Mental Illness COPD High Blood Pressure Any other important illnesses? Are you allergic to any medicines or dressings? If Yes please give details (Please circle) YES NO

Please list any medications you are taking

Do you smoke? (Please circle) YES NO Are you an ex-smoker? (Please circle) YES NO If Yes how many a day? Would you be interested in smoking cessation advice? (Please circle) YES NO How many units of alcohol do you drink in a typical week? [ ] (one unit is a glass of wine, one measure of spirit or half a pint of beer) What is your height in cm? What is your weight in kg?

What would you consider your Ethnicity to be? (Please circle) African Bangladeshi British or Mixed British Caribbean Chinese Indian or British Indian Irish Other Asian Background Other Black Background Other Mixed Other White Background Other Background Pakistani or British White and Asian White and Black African White and Black Pakistani Caribbean Are you an English Speaker? (Please circle) YES NO First Language spoken

Please give details of any pregnancies (eg 1997 girl, born at 40 weeks by forceps)

Please give the approximate date of your last smear test What contraception are you currently using?

Do you have any specific communication needs? Please tick □ Blind □ Partially sighted □ Deaf □ Hearing Impaired □ Deafblind □ Memory problems □ Learning disability □ Autism Other (Please specify) If you ticked one of the above, how should we contact you? (e.g. large font letters, via a carer/family member. Unfortunately we are not able to offer Braille.)

If you would like us to contact you via another person please provide their details.

Would you like a Summary Care Record creating? (Please circle) YES NO See attached information on Summary Care Records

Your allocated named General Practitioner will be Dr Sarah Johns. However, we are a group practice and as such you are still able to see any GP for your problem depending on availability.