Welcome to Wonersh Surgery. In order for us to provide you with the best medical care please complete this Questionnaire and pass to Reception.
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1 PATIENT QUESTIONNAIRE WONERSH SURGERY Welcome to Wonersh Surgery. In order for us to provide you with the best medical care please complete this Questionnaire and pass to Reception. DETAILS ABOUT YOU: Please Enter Today s Date: Forename: Surname: Sex: Male / Female Date of Birth: Marital Status: Religion: Address: Home Tel: Mobile: The Surgery uses a texting service to remind patients about appointments etc, please tick here if you DO NOT wish to be contacted by text Communication: First Language Spoken? Do you need an interpreter? Do you have any particular information or communication needs? How can we best meet these needs? Do you give your consent for us to share your communication needs with other NHS & adult social care providers? Next of Kin Name: Relationship & Contact Details: Do You Have A Carer? Details: Yes / No Are You A Carer? Details: Yes / No
2 DETAILS ABOUT YOUR HEALTH: Height: Weight: How much alcohol do you drink in the average week? (units) This is one unit of alcohol and each of these is more than one unit Alcohol Consumption: Please circle which box is appropriate for the questions below Scoring System Your Score How often do you have a drink that contains alcohol? How many standard alcoholic drinks do you have on a typical day when you are drinking? How often do you have 6 or more if female, or 8 or more if male, on a single occasion in the last year? Never Monthly or less 2-4 times per month 2-3 times per week 4+ times per week Never Less than Monthly Monthly Weekly Daily or almost daily Do You Smoke? YES / NO If yes, how many do you smoke (per day): If NO, are you an ex-smoker YES / NO When did you give up? How many did you smoke (per day)? How would you describe your level of physical activity? A very active B moderately active C Slightly active D Inactive How would you describe your diet? A Vegetarian B Good C Fair D Poor
3 Do you have any of the following medical conditions: Heart Disease YES/NO Hypertension (blood pressure) YES/NO Stroke/TIA (Mini stroke) YES/NO Diabetes YES/NO Asthma YES/NO COPD (chronic bronchitis) YES/NO Cancer YES/NO Serious Mental Illness YES/NO If you have answered YES to any of the above, please make an appointment to see your new GP Do you have any other series medical conditions OR have you had any major operations YES/NO Please Give Details: What form of Contraception do you use? Are you allergic to any drugs YES/NO If YES, please state drugs and nature of allergy: Do you have any other allergies? YES/NO If YES, please state drugs and nature of allergy: Have you received a Summary Care Record Information Pack? YES / NO Prescriptions: Where would you like your prescription to go. Name of pharmacy: EPS (electronic prescription service) If you would prefer your prescription to be sent electronically to a pharmacy of your choice then please refer to the leaflet in the new patient pack.
4 DETAILS ABOUT YOUR FAMILY: Do any members of your family (mother, father, sister(s), brother(s), grandparents) have the following:- Heart Disease (before age 60) YES/NO Details (inc family member) Heart Disease (after age 60) YES/NO Details (inc family member) Stroke YES/NO Details (inc family member) Diabetes YES/NO Details (inc family member) Asthma YES/NO Details (inc family member) Cancer YES/NO Details (inc family member) If you would like a healthcare check. Please book an appointment with the Healthcare Assistant or your GP.
5 PATIENT ETHNIC ORIGIN QUESTIONNAIRE This questionnaire follows the recommendations of the Commission for Racial Equality and complies with the Race Relations Act. Please indicate your ethnic origin. 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. If you do not wish to complete this Questionnaire, please print your name and tick the box at the bottom of the form. Name: Date of Birth: A White British Irish Any other white background please write in below B Mixed White and Black Caribbean White and Black African White and Asian Any other mixed background please write below C Asian or Asian British Indian Pakistani Bangladeshi Any other Asian background please write below D Black or Black British Caribbean African White and Asian Any other black background please write below E Chinese or other ethnic group Chinese Any other please write below I do not wish to complete this questionnaire. Please tick box
6 DETAILS ABOUT IMMUNISATIONS: Age Vaccination Date Given 2 months old Diphtheria, tetanus, pertussis, polio and haemophilus influenzae tybe b (hib) Rotavirus Meningococcal group B (Men B) 3 months old Diphtheria, tetanus, pertussis, polio and haemophilus influenzae tybe b (hib) Rotavirus Meningococcal group C (Men C) 4 months old Diphtheria, tetanus, pertussis, polio and haemophilus influenzae tybe b (hib) Meningococcal group B (Men B) Between 12 & 13 months old 2, 3 and 4yr old children in school yrs 1 & 2 Measles, mumps and rubella (MMR german measles) Hib / Men C Influenza (from September 2014) 3 yrs and 4 months Diphtheria, tetanus, pertussis and polio Measles, mumps and rubella Girls aged 12 to Cervical cancer - HPV 13yrs Around 14 yrs MenACWY Year 13 students MenACWY (aged 17-18) Any Others please list Hepatitis A Hepatitis B Typhoid Hepatitis A + Typhoid Yellow Fever Rabies Shingles
7 WONERSH SURGERY NEW PATIENT REGISTRATION CHECKLIST (For Office use only) 2 x Proof of Identity: 1 x Photographic 1 x New Address Summary care record pack given Purple Form Title Gender Surname First Names NHS Number (if available) Previous Surname Date of Birth Place of Birth (Place & County if London Area which Borough) New Address with Postcode Previous Doctor s Name & Surgery Address From Abroad Date of Entry to UK Ex-Services: Date of Enlistment Date of Discharge Patient Questionnaire Questionnaire Completed Fully Tick Completed Checked By
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5. Statement of Applicant Health Applicant Name: Date of Examination: Height: Weight: Blood Type (If known): Physician must answer each of the following questions. To be completed by attending physician.
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