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1 Personal Details 2 Health Dr Paul Manchett Dr Adrian Townsend Dr David Simpson Dr Natalie Avery Dr Edward Gibbons Dr Claire Walsh Dr Julia Snyder Stockbridge Surgery, New Street, Stockbridge, Hampshire. SO20 6HG Welcome to Stockbridge and Broughton Surgeries. It often takes many weeks before the records arrive from the previous Doctor. To help us until then, please fill in the form below as completely as you can. Please complete or tick box next to the most appropriate statement. 1 Personal Details Surname: _________________ Forenames: _______________________ Title _________________ Sex: Male / Female Date of Birth: _________________ Marital status _______________________ Address: ____________________________________________________________________ ____________________________________________________________________ Post code: _________________ Home Tel: _________________ Work Tel: _______________________ Mobile: _________________ Occupation: _______________________ 2 Health 2.1 Smoking 2.2 Alcohol I have never smoked A unit is one pub measure of spirits, one glass of Gave up ? years ago/smoked ? per day / wine or half a pint of beer or cider I smoke less than 1 cigarette per day I smoke 1-9 cigarettes per day(light) How many units per week do you drink? I smoke 10-19 cigarettes per day(mod) (please state approximate number ) I smoke 20-39 cigarettes per day(hvy) 2.3 Height/Weight I smoke more than 40 cigarettes per day (vhvy) Height: ………ft………ins, or……………m I smoke ? cigars per day I smoke a pipe. ? oz’s per week I smoke ‘roll your own’ cigarettes Weight: ………st………lbs , or …………kg Please note this is a Personal History Form; please complete a Registration Form GMS1 at the surgery Please turn over 3 Family History Does / Did she / he have ? ( Please tick box if YES) Cancer Relation Living Age Heart High Diabetes Glaucoma Asthma Stroke (Please or Disease Blood state type Deceased Pressure e.g breast, bowel) Father Mother Other Blood Relatives ( grandmother/grandfather/sister / brother) 4 Allergy to Medication Are you allergic or sensitive to any medication? YES* / NO *If YES please name / give further details: ………………………………………… ………………………………………… ……………………………………… 5. First Spoken Language Please specify…………………………………………………. 6. Ethnic Category White British Black or Black British Black Caribbean Irish Black African Other White Other Black Mixed White/Black Caribbean Other Ethnic Chinese White/Black African Japanese White/Asian Other Ethnic Category Other Mixed Asian Indian Pakistani Declined Bangladeshi Other Asian THANK YOU for completing this form for our records. If on medication, please arrange a New Patient Health Check with a doctor. Please bring a record of all your medications and a urine sample when you attend. Please note this is a Personal History Form; please complete a Registration Form GMS1 at the surgery F.A.S.T ALCOHOL QUESTIONNAIRE 1. MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion? 1 drink = ½ pint of beer or 1 glass of wine or 1 single spirits (√) Please tick one box below Never Less than Monthly Weekly Daily or almost monthly daily √ 2. How often during the last year have you been unable to remember what happened the night before because you had been drinking? (√) Please tick one box below Never Less than Monthly Weekly Daily or almost monthly daily (√) 3. How often during the last year have you failed to do what was normally expected of you because of drinking? (√) Please tick one box below Never Less than Monthly Weekly Daily or almost monthly daily (√) 4. In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? (√) Please tick one box below No Yes, on one occasion Yes, on more then one occasion (√) Dr Paul Manchett Dr Adrian Townsend Dr David Simpson Dr Natalie Avery Dr Edward Gibbons Dr Claire Walsh Dr Julia Snyder Practice Manager: David Wharton STOCKBRIDGE SURGERY NEW STREET STOCKBRIDGE HAMPSHIRE SO20 6HG Tel: 01264 810524 Fax: 01264 810591 e-mail: [email protected] website: www.stockbridgesurgery.co.uk Repeat prescription reorder form When you receive your repeat prescriptions which have been with dispensed by the surgery or by the chemist you should find attached a reorder slip. You may use this slip to reorder your medication or you may order your medication online using EMIS Access. At the bottom of the reorder slip it will state a review date. You need not worry about this date; it is used by the surgery. However, if when processing the item the Doctor would like you to make an appointment with the surgery to see the Doctor, Practice Nurse or Phlebotomist this will be either printed or written at the bottom of the reorder slip underneath the review date. If this request is on your reorder slip then you need to call the surgery to make an appointment. In order to use EMIS Access you need to ask at Reception for a Practice ID, Personal Access ID and on-line access instructions . Stockbridge Surgery Partners: Dr P Manchett, Dr A Townsend. Dr D Simpson, Dr N Avery, Dr E Gibbons, Dr C Walsh Our Dispensing Service The Stockbridge Surgery dispensary is available for use by our patients living more than a mile (1.6 km) as the crow flies, from the nearest pharmacy. The law does not extend the right to patients within the 1 mile zone. The opening hours are Monday – Friday 8.15am to 6.30pm (closed for lunch between 12.45- 1.45pm). Saturday 9am to 12pm (for collection of medication and prescriptions The dispensary is managed by Veronica Ayres who has over 20 years experience in running our dispensary. She has a dedicated team of dispensers who run an efficient, well organised service. They are happy to discuss your queries and will refer to a doctor if required. We also run a smaller dispensary at Broughton which is useful for acute illnesses and for picking up your repeat medication. We pride ourselves in holding a large stock of medicines and we can usually provide you with medication to treat acute illnesses before you leave the surgery. On rare occasions we may have to obtain them from our suppliers; this is usually achieved within 24 hours. Re-ordering medication There are 4 ways to re-order your medication: 1 Internet. The system (EMIS) is easy to use and can be accessed via our website: www.stockbridgesurgery.co.uk You will need to contact the surgery to obtain a unique log-in number to set up your access process. Please ask at reception for details. 2 In person. Use the repeat medication form enclosed with medicines. Simply tick the required items and leave the form at your usual drop off point i.e. one of our surgeries or at the appropriate village post office. 3 Post. Mail the repeat form or a clearly written request to Stockbridge Surgery [address overleaf] 4 Fax Fax to Stockbridge Surgery [number overleaf] Order in good time In general, you should allow 48 hours from handing in your prescription to collecting the medication. If you need the drugs sooner, please check with our Dispenser first that they are in stock, In order to prevent waste, only re-order medication that you currently need. Collection & Delivery Service We provide a collection and delivery service three times a week in the following areas: Chilbolton, King’s Somborne, Leckford and Over Wallop. We also have a weekly service which covers Grateley. Nether Wallop, Lockerley and the West Tytherley areas. We pick up all repeat medication requests as they all need to be processed by us. For our dispensing patients we will deliver your medication back to the appropriate village post office, usually within two working days. Non-dispensing patients can collect their forms from the designated surgery (Stockbridge or Broughton). We will post your new prescription form back to you if supplied with a stamped, addressed envelope. Prescriptions to be dispensed by the local town pharmacy are collected from us each day after processing. Emergency Pharmacies When the Surgery is closed, you can take your prescription to any Pharmacy of your choice to be dispensed. Cover is also provided on the following days in Andover: Saturdays Boots the High Street, Andover, to 5.30pm Boots the Chemist , Chantry Centre, to 6.00pm Superdrug , High St, Andover to 5.30pm Sundays Boots the Chemist , Chantry Centre, Andover. 10.00—4.00 Further details of Pharmacy late opening and weekends are displayed at the Surgery. Comments We welcome your comments regarding the dispensary. If you have any suggestions to improve the service or issues you would like to raise, please speak to either Veronica Ayers, Senior Dispenser, or the Practice Manager, Mr David Wharton. Stockbridge Surgery New Street Stockbridge Hampshire SO20 6HG Stockbridge : 01264 810524 Broughton : 01794 301210 Dispensary : 01264 811021 Fax: 01264 810591 Email: [email protected] Do something amazing today ! When you give blood, you will be doing one of the most amazing things anybody could dream of – saving a life. You can enable someone to receive a gift of a desperately needed transfusion. Every day of the year, hospitals in England need 10,000 donations of blood – and the demand is rising all the time as medical techniques become ever more sophisticated. But only 5% of the UK population currently give blood It is all types of blood that are needed – not just rare ones. In fact, the commoner the blood, the more is needed. So even if your blood id O, for example – you can be sure that by donating regularly, two or three times a year, you really are doing something amazing By enrolling as a blood donor, or if you have given blood but not recently, why not enrol today? It could not be simpler, just take two minutes to complete the form below and hand it in at the surgery reception.
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