NEW PATIENT INFORMATION CARD Surname ………………………………First name(s) ……………………………….. Full address……………………………………………………………………………. …………………………………………………………Post Code ………………….. Tel No. home……………… Work …………………Mobile No……………………. Sex ……. M / F Date of birth ………………. Marital Status …………………… Occupation…………………………………………………………………………… Have you been registered at this surgery before? Yes No GENERAL HISTORY Do you suffer for any of the following conditions? Please tick appropriate boxes Diabetes Asthma COPD High Blood Pressure Stroke Heart Disease Epilepsy Hypothyroidism Mental illness What medicines are you taking? ………………………………………………………. ……………………………………………………………………………………………………………. Have you any allergies to medicines or anything else?………………………………… Smoking status – never smoked  ex-smoker  when did you stop?……… smoker  How many cigarettes / how much tobacco do/did you smoke? …….per day Are you a carer? Do you look after someone close to you, who through reasons of illness, disability, frailty, or an alcohol or drug problem, is unable to manage without your help? Yes  No  If yes, please ask at reception for a questionnaire. FAMILY HISTORY please tick appropriate boxes Which of your blood relations have suffered the following? Heart Attack  ………………… Cancer  …………………………….. Diabetes  ………………………. High blood pressure ……………….. Asthma  ……………………….. Tuberculosis  ……………………….. Stroke  …………………………. Other serious Illness  ……………….

FOR FEMALE PATIENTS ONLY Have you had any children?  give ages ……………………………… Have you had a termination of pregnancy?  give date …………………………….. Have you had a hysterectomy?  give date …………………………….. What method of contraception are using at present? ………………………………….

Please turn over When was your last smear? …………………………………………………………… How much alcohol do you consume per week? (quantity in units) Wine ………………… Beer ………………. Spirits ………………….

Questions Scoring system Your 0 1 2 3 4 Score How often do you have a drink Never Monthly or 2-4 times per 2-3 times 4+ times that contains alcohol? less month per week per week How many standard alcoholic drinks do you have on a typical 1-2 3-4 5-6 7-8 10+ day when you are drinking? How often do you have 6 or more standard drinks on one occasion? Never Less than Monthly Weekly Daily or monthly almost daily

Do you pay for your prescriptions? Yes No If yes, do you hold a pre-payment certificate? Yes No

DO NOT COMPLETE THIS SECTION Date Urine Glucose Albumin

BP Weight Height

Please turn over PATIENT ETHNIC ORIGIN This follows the recommendations of the Commission for Racial Equality and complies with the Race Relations Act.

Please indicate your ethnic origin and first language. This is not compulsory, but may help with your healthcare, as some health problems are more common in specific communities, and knowing your origins may help with the early identification of some of these conditions.

Choose ONE section from A to E, and then tick ONE box to indicate your background. A White British Irish Any other white background please state:

B Mixed White and Black Caribbean White and Black African White and Asian Any other mixed background please state:

C Asian or Asian British Indian Pakistani Bangladeshi Any other Asian background please state:

D Black or Black British Caribbean African White and Asian Any other black background please state:

E Chinese or other ethnic group Chinese Any other please state:

Please turn over the page

Please turn over First Language – please tick

001 Akan (Ashanti) 002 Albanian 003 Amharic 004 Arabic 005 Bengali 7 Sylheti 006 Brawa & Somali 007 British Signing Language 008 Cantonese 009 Cantonese & Vietnamese 010 Creole 011 Dutch 012 English 013 Ethiopian 014 Farsi(Persian) 015 Finnish 016 Flemish 017 French 018 French creole 019 Gaelic 020 German 021 Greek 022 Gujarati 023 Hakka 024 Hausa 025 Hebrew 026 Hindi 027 Igbo (Ibo) 028 Italian 029 Japanese 030 Korean 031 Kurdish 032 Lingala 033 Luganda 034 Makaton (sign language) 035 Malayalam 036 Mandarin 037 Norwegian 038 Pashto (Pushtoo) 039 Patois 040 Polish 041 Portuguese 042 Punjabi 043 Russian 044 Serbian/Croatian 045 Sinhala 046 Somali 048 Spanish 049 Swahili 050 Swedish 051 Sylheti 052 Tagalog (Filipino) 053 Tamil 054 Thai 055 Tigrinya 056 Turkish 057 Urdu 058 Vietnamese 059 Welsh 060 Uoruba 200 Other

I do not wish my ethnic origin or first language to be recorded

Signature………………………………………………………………………..

Print Name ……………………………………………………………………..

Date ………………………………………………………………………………

Please turn over