Yellow PracticeNewPatient Infmation Card Date / / Surname MR/MRS/MISS/MS First Name(s) Date of Birth / / Home Tel: Wk Tel: Mobile Tel: Email Address: Address Post Code Height Weight Occupation Are you a CARER HAVE A CARER (please circle applicable) N/A Name of the son whois cared f OR is the carer First/Last Name Date of Birth / / Telephone No s: Address Post Code ETHNICITY please circle British Mixed British Indian British Indian Irish Pakistani British Pakistani OTHER background please state: MAIN LANGUAGE Other White background Bangladeshi British Bangladeshi White & Black Caribbean White and Black African White and Asian Caribbean African Chinese please circle one English French German Spanish Dutch Polish Italian Greek Japanese Nwegian Swedish Turkish Russian Welsh Arabic Punjabi Hindi Guajarati Tamil Urdu Farsi OTHER pleasestate: ~PTO~
SMOKING QUESTIONNAIRE (f all patients aged 15 and over) SMOKING I am a smoker Please tick How many day? I stopped smoking Date stopped. /. /. Since.. I never smoke FAMILY HISTORY and PERSONAL HISTORY Has any of your family been diagnosed with? Please complete Heart disease Cancer Diabetes Stroke Asthma TB Have you had any serious illness oations X rays test, please state when? What medicines are you taking? ALLERGIES: Do you have any? Women ONLY How many pregnancies have you had? Have you had a hysterectomy? YES / NO Number:. If yes, please give date.. NEXT OF KIN Name: Relationship:.. Address:.. Post Code:. Telephone Number:..
This is one unit of alcohol and each of these is me one unit AUDIT C Questions How often do you have a drink containing alcohol? How many units of alcohol do you drink on a typical day when you are drinking? Scing system 0 1 2 3 4 less 2-4 month 2-3 week 4+ week 1-2 3-4 5-6 7-9 10+ Your sce How often have you had 6 me units if female, 8 me if male, on a single occasion in the? Scing: A total of 5+ indicates increasing higher risk drinking. An overall total sce of 5 above is AUDIT-C positive. SCORE
Sce from AUDIT- C (other side) SCORE Remaining AUDIT questions Questions How often during the have you found that you were not able to stop drinking once you had started? How often during the have you failed to do what was nmally expected from you because of your drinking? How often during the have you needed an alcoholic drink in the mning to get yourself going after a heavy drinking session? How often during the have you had a feeling of guilt remse after drinking? How often during the have you been unable to remember what happened the night befe because you had been drinking? Have you somebody else been injured as a result of your drinking? Has a relative friend, doct other health wker been concerned about your drinking suggested that you cut down? Scing system 0 1 2 3 4 No No but not in the but not in the during the during the Your sce Scing: 0 7 Lower risk, 8 15 Increasing risk, 16 19 Higher risk, 20+ Possible dependence TOTAL Sce equals AUDIT C Sce (above) + Sce of remaining questions TOTAL = =