Microsoft word - welcome to our practice registration form.rtf

THE ST JAMES PRACTICE – Registration Form 1 Welcome to our Practice. We hope that you will be happy with the care we provide for you. Our aim is to provide you with advice on many health issues and, hopefully, to keep you in good health. Please complete as many of the following questions as you can. This information is COMPLETELY CONFIDENTIAL and will help us to provide you with the appropriate medical care for your needs. DATE OF NEW PATIENT MEDICAL CHECK (where appropriate) ______________________________ (Please bring a sample of urine in a clean container when you attend). Are you a Carer? (Do you look after a relative or friend who is sick, disabled, elderly, has mental health problems Do you have a disability / any special requirements that Date of entry into the UK (if not born here)? Are you a refugee or an asylum seeker? Yes No Which ethnic group do you feel you belong to? WHITE: White British / Irish / Other white (please bring a copy of immunisation records to the MIXED: White & Black Caribbean / White & Black African / White & Asian / Other mixed (please specify) NAME OF NEXT OF KIN: (please state relationship to Bangladeshi / Indian / Pakistani / Other Asian Chinese / any other (please specify) DO YOU CONSENT TO US SENDING YOU SMS TEXT THE ST JAMES PRACTICE – Registration Form 2 FAMILY HISTORY: Do YOU or any of YOUR RELATIVES suffer from the following conditions? (Please appropriate boxes below) YOUR PAST MEDICAL HISTORY (please list any serious illness, operations or accidents with dates) TYPE OF OPERATION, ILLNESS, ACCIDENT or CONDITION CURRENT MEDICATIONS (please include any medicines you regularly purchase from the chemist or other retail outlet) ON PRESCRIPTION PURCHASED FROM CHEMIST/ SHOP If YES - how many per day OR how many grammes of tobacco? If yes – when did you stop : Are you interested in stopping and being referred to THE ST JAMES PRACTICE – Registration Form 3 ALCOHOL: How many units of alcohol do you consume in one week? EXERCISE: Do you take any form of exercise? DIET Do you eat a healthy balanced diet? Have you any special dietary requirements? If YES please specify: VACCINATIONS: When did you last have the following vaccinations? Influenza (only if you are over 65 years of age or in an ‘At Risk’ group. i.e. CHD, stroke, diabetic, COPD of Asthmatic) Pneumonia Vaccine (should be given in you are 65 years or age or over OR in an ‘At Risk’ group, i.e. CHD, stroke, diabetic, COPD of Asthmatic) THE ST JAMES PRACTICE – Registration Form 4 WOMEN ONLY: Are you pregnant or could you possibly be pregnant? Please state what method of contraception you use If using Depo Provera, when is your next injection due? When and where did you last have a Cervical Smear Test? (if you have a copy of the result, please bring it to the surgery when you attend for your health check) Have you had any previous abnormal smear results? Number of births _______ Number of miscarriages _________ Number of terminations _________ Have you had a hysterectomy? Yes No If YES please state date and name of hospital ________________________________________________________ Do you take HRT? Yes No IMPORTANT NOTE: Contraceptive and HRT pills are not given as repeat prescription items without first having a check up with our Practice Nurse. At that appointment a six month supply will normally be prescribed. IS THERE ANY OTHER INFORMATION YOU WOULD LIKE TO TELL US THAT WILL HELP US TO PROVIDE YOU WITH THE APPROPRIATE MEDICAL CARE FOR YOUR NEEDS? …………………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………………. Name : ………………………………………… Signature: ………………………………………… Date: ……………………………… TO BE COMPLETED BY THE PRACTICE NURSE AT YOUR HEALTH CHECK APPOINTMENT Date of Health Check: N:\Secretaries\FORMS,POSTERS,SLIPS\Welcome to our Practice Registration Form.rtf

Source: http://www.thestjamespractice.co.uk/NP/Practice%20Registration%20Form.pdf