Forms

Online Patient Registration Health Check

All fields marked * are required.

Full Name: *

Date of birth: *

Day: Month: Year:

Your Health

Height: *

Weight: *

Do you smoke? *

Yes No

If yes, how often do you smoke? (number per day)

Cigarettes:

Pipe:

Cigars:

Has your GP or nurse given you advice about smoking?

Yes No

If you do not smoke, have you ever smoked?

Yes No

If you would like help and support to stop smoking, the surgery is pleased to offer this service. Please make an appointment with the Practice Nurse.

Do you drink alcohol? *

Yes No

If yes, how much do you drink? (units per week)

Wine:

Beer or cider:

Spirits:

Other:

Current History

Please tell us if you have:

If you would like to comment, please provide details here:

Do you have any other condition, not mentioned above?

Do you have any allergies? Please provide details:

Are you currently taking any medication? Please provide details:

Please note that if you require regular medication you must book an appointment to see a GP.

Personal History

Please provide us with details of any serious illness or operations you have had:

Date or year:

Details:

Childhood immunisations (for patients coming from abroad only):

Date or year:

Details:

Family History

Please indicate where there is any history of the following in your family:

	Father	Mother	Siblings	Grandparents
Diabetes
Heart Disease
High Blood Pressure
Asthma
COPD
Epilepsy
Stroke
Kidney Disease
Hypothyroidism

Female Patients Only

Have you been vaccinated against Rubella?

Yes No

Are you currently using contraception? If so, please provide details:

When was your last smear taken?

When is your next smear due?

Are you experiencing the menopause?

Yes No

All Patients

Is there anything regarding your health you would like to bring to our attention?

Thank you for taking the time to complete this form. We look forward to meeting you in the surgery.

For peace of mind, we offer all patients the choice of a Well Man Check, Well Woman Check or (for patients of 15 – 24 years of age) a Young Person Check. Please contact the surgery to book.

If you find it difficult to visit the surgery, please note that extended opening hours are available on Saturday mornings and Thursday evenings.

Please complete the online Contact Preferences Form if you have not already done so.