Yes No - GP Web Solutions

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Forge SurScrY, AnneEoreg - Pationt Quastionnaire
Conficlentia!. FarrrL
Address
First Name
Surnarae/Famillr
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5u*"
Sex
Fostcode
Date of Birth
Telephone No
Marital Statrts
Occupation
Frincipal Language
Yes/NIo
F{ave you been registered here before?
If "Yes" what was your name at that time?
Mobiie No
WorkNo
Emaii
RelationshiP to You
I'Iext of Kin
Tel.ldo.
Address
answer as fullv as Ysg
Fersoma[ Medic.ai F{
Flease tick the a
Do you sufier from an of the foilowi s ilinesses?
Date qf
Yes No
Disease
diagnosis
answer.
Asthma
Eczema
COFD / Bron;hitis
Heart Disease
Ainal fibnliaiton
F{igh Blood Fressure
Diabetes
Cancer
Epitrepsy /Fits
Depression
AnxietY
SchizoPhreniri
Obesit5z
Stroke
Chronic KidneY Disease
Learning Difficulties
Height
_.-
!:-<
Please check
Weigirt
if
Are you on AsPirin?
You a
opefatrons'
illnesses you have or have had' including any
Please give details of any other important
Ifanyofyourfamily/closerelativessufferec]fromanyofthediseasesabove'pleasegivedetails.
Flease {ist ail the iriedicines you fake or
aftach
r Fc"evio{is S$a
Flease list dia osis if known. (If child ease
also lis.{ vaccinations had and ciates
Msdication / Chitd vaccs.
Nurntrer tirnes/da
Diagilosis / lut" of v*.l.t,toi
[If
your are on a prescripfion f,or naethadone,
dihydrocodeine,
p{ease see neceptiom ior further detailsJ
or deazepam ro" ug*ou** problems,
Are you Ailergic to any medicines.fplease list]
Are you Ailergic to eggs.
F{ave you ever had a reaction to a vaccinaiion_
fPlease give detailsl
1\O
Some Qwestioyas sbowt
Smo[<inE
Never
Ex smoker
Cuirent
Yes
tick and.
No
detaiXs where asked
Alcoleol
Never
Yes - Fiow much per week
Date of sropping
FIow many p", Auy
Shorts_ Fints.--
Wine
Used to Cdnk heavrtry but iiot nou,/
trf
you wouid liice to stop snaokang pleese ask
at
R.eception to put your nar-rie down
:
Total now
I{V9;:tldnkyou;ffi
for our
alcoinol ared woutrd iilie help,
$tr**uu rmake
f,iraent witle a doc$or
ac?
Previcusiy fbut not
Females Only
Last Smear Test : Date
NormaVAbnormal
Where srnear t.aken
Hcv" many children
Hysterectomy [reason if known]
Any miscarriages/still births/terminations
[give detailsl
When next due
Curent methods of C
fl-White British
n
White Irish
Other white background (please state)
I
I
I
Asian - Indian
Asian - Pakistani
Asian - Bangladeshi
Signed
Other Asian background (please state)
n
Black Caribbean
D Black African
tr
White & Asian
n
Black & Asian
rt (-h;...^
Other Black background (please state)
D White & Black
tr
Caribbean
Any other ethnic group(please state)
Other mixed race (please state)
White & Black African
Date
BP