To Help Us Help You, Please Complete Below and Overleaf

HASSENGATE MEDICAL CENTRE, SOUTHEND ROAD, STANFORD-LE-HOPE SS17 0PH Tele. 01375 808210

To help us help you, please complete below and overleaf

Photographic identification and proof of residency – required for all new patients

Patient group – Please be part of our group. For more details about the group and to contact them please see www.hassengatemedicalcentre.co.uk

Exercise How often do you exercise vigorously enough to get flushed for 20 minutes or longer in a week? Please circle one of the following: Never/Rarely Once Twice Three State how many if more - - -

Diet If you are on a specific diet please circle the diet you are on- Vegetarian Low salt Vegan Milk free Weight reducing Egg free Low fat High fibre

Female Patients - If you require Family Planning Treatment / Advise or are or have recently been pregnant please make an appointment with Nurse / Doctor as soon as you can after receiving acceptance onto our list.

About you Family Please indicate if your Mother / Father / Sister / Brother have developed whilst aged less than 60yrs any of the following: Asthma / Diabetes / Stroke / Heart attack / Angina (Example Father – aged 57yrs - Stroke)

Do you or anyone living with you suffer from an addiction? If yes – please state who and what.

Please ring any of the following major conditions or operations you have had or still suffer from: Heart problems; Diabetes; Breathing difficulties; High blood pressure; Kidney problems; Epilepsy; Renal problems Depression or mental health problems.

Please be assured your medical condition is not a consideration for acceptance onto this Doctors list! We simply need to know promptly so we can organise any needed care.

New Patients can choose to have a new patient health check, if you would like such an appointment please let us know and note that you will be asked to attend with a urine sample, (bottles are available from reception) .

Signed …………………………………………………….DATE ………………

Please continue overleaf,

RJV / REVIEW 7-May-18 / PAGE 1 of 3 / D:\Docs\2018-04-10\02e2fac6073c4032efa3f31c0523246b.doc Initials of staff taking in form Registration details– Where “YES / NO” please circle one

RJV / REVIEW 7-May-18 / PAGE 2 of 3 / D:\Docs\2018-04-10\02e2fac6073c4032efa3f31c0523246b.doc Surname/Family name First name(s) If known by another name, please detail Date of Birth If under 16yr old – additional form to complete – please ask at reception Occupation/School/Nursery Next of kin – YES / NO If Yes please supply name and address/ relationship and contact telephone number:

Are you a Carer? YES / NO If yes for a patient here – please ask for form Do you have a Carer – YES / NO If yes – please ask for form from reception Photographic I/d presented YES / NO Confidentiality - you information will be shared for SCR / General purposes - Opt out form is available – please ask reception First Language Telephone number Mobile number Avoid the same number for household Email address Online - wanted? YES / NO If yes – please ask for form from reception Text service wanted? YES / NO Care – more than one on same No. in household (Do not use same No. for 11-18yr olds) On Medication? YES / NO Please see below Allergies? YES / NO Please detail Do you smoke? YES / NO How many a day / when did you stop? We recommend that all smokers consider quitting via our smoking cessation clinic – Please ask for appointment once you have confirmation of joining us. Please indicate your height Please indicate your weight Please state your last blood pressure level if known Please complete the audit on the next page if you are aged 16yrs or older Do you have a problem with drink / alcohol / gambling? Would you like help with this problem? Ethnicity: White British; White Irish; Other white; Mixed Caribbean; Mixed African; Mixed White Asian; other mixed; Indian; Pakistani; Bangladeshi; Other Asian; Black Caribbean; Chinese; Turkish; Black African; other black background; other ethnic background – please detail ………………… Medication If you take herbal medicines please let us know. Please bring in the empty cartons or repeat slip so that medication can be added to our system – A hand written note of current medication is not acceptable. Please also note that until you have been seen by one of the doctors of this practice only one month’s supply will be issued. Please make an appointment with Doctor to discuss your medicines as soon as you have received confirmation that you have been accepted onto this practice’s list.

For safety reasons requests for repeat medication are not accepted over the telephone. This is one unit of alcohol…… and each of these is more than one unit

RJV / REVIEW 7-May-18 / PAGE 3 of 3 / D:\Docs\2018-04-10\02e2fac6073c4032efa3f31c0523246b.doc Scoring system Your FAST 0 1 2 3 4 score Daily How often have you had 6 or more units if Less or female, or 8 or more if male, on a single Never than Monthly Weekly almost monthly occasion in the last year? daily Daily How often during the last year have you failed to Less or do what was normally expected from you Never than Monthly Weekly almost monthly because of your drinking? daily Daily How often during the last year have you been Less or unable to remember what happened the night Never than Monthly Weekly almost monthly before because you had been drinking? daily Yes, Yes, Has a relative or friend, doctor or other health but not during worker been concerned about your drinking or No in the the suggested that you cut down? last last year year Scoring: If score is 0, 1 or 2 on the first four questions– STOP HERE. An overall total score of 3 or more is FAST positive, so complete ALL 10 questions. Scoring system Your Questions 0 1 2 3 4 score 2 - 4 2 - 3 4+ How often do you have a drink containing Monthly times times times Never alcohol? or less per per per month week week How many units of alcohol do you drink on a 1 -2 3 - 4 5 - 6 7 - 8 10+ typical day when you are drinking? Daily How often during the last year have you found Less or that you were not able to stop drinking once you Never than Monthly Weekly almost monthly had started? daily Daily How often during the last year have you needed Less or an alcoholic drink in the morning to get yourself Never than Monthly Weekly almost monthly going after a heavy drinking session? daily Daily Less How often during the last year have you had a or Never than Monthly Weekly almost feeling of guilt or remorse after drinking? monthly daily Yes, Yes, but not during Have you or somebody else been injured as a No in the the result of your drinking? last last year year TOTAL AUDIT Score (all 10 questions completed): 0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence

RJV / REVIEW 7-May-18 / PAGE 4 of 3 / D:\Docs\2018-04-10\02e2fac6073c4032efa3f31c0523246b.doc