docYours sincerely - Haigh Hall Medical Centre
download 
Report Transcription
Yours sincerely - Haigh Hall Medical Centre
Haigh Hall Medical Centre CONFIDENTIAL MEDICAL HISTORY FORM To obtain high quality and safe treatment, the Practice Clinical team need to know about any problems which may affect your health. Please complete this form at the time of registration. A member of our Practice Team may contact you by telephone after updating your records with the information supplied by you in this questionnaire. Please provide a DAYTIME TELEPHONE NUMBER below where you can be contacted. Title:_____ Forenames:__________________________Surname:_____________________ Telephone: Home:________________Mobile:__________________Work:_________________ Email address:____________________________________DOB ________________________ Do you consent to receiving text messages reminding you of appointments? Are you: No Taking any prescribed medicines (e.g tablets, ointments, injections, contraceptives) Yes No Yes Details ______________________ ______________________ Please attach your repeat slip from your previous GP If you are taking 4 or more medications please make an appointment to have your medication reviewed ____________________________________________________________________________ Do you have any allergies or sensitivities? ______________________ Do you have: No Yes Diabetes? A pacemaker Heart problems such as: (such as heart attack, angina or heart surgery) ______________________ ______________________ ______________________ ______________________ ______________________ Stroke/Mini Stroke COPD, Bronchitis, asthma or other chest conditions? Epilepsy? Thyroid Problems? High Blood Pressure (Hypertension)? ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ Haigh Hall Medical Centre Does your family have a history of: No Yes Details: Heart disease under the age of 60? Heart disease over the age of 50? A stroke? Diabetes? Asthma? Cancer ? Raised Cholesterol? High Blood Pressure (Hypertension)? __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ Weight management: Height_____________________________ Weight_____________________________ Smoking: No Yes Details Do you smoke? Cigarettes, tobacco, other substances? ________________________ ________________________ Are you an ex-smoker? ________________________ If yes when did you quit?____________________________________________________ If you would like help in stopping smoking please make an appointment with one of our stop smoking advisers. Haigh Hall Medical Centre Number of alchol units taken weekley Alcohol Use: yes No Do you drink alcohol 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? How often have you had a 6 or more units if female, or 8 or more if male, on a single occasion in the last years? How often during the last year have you found that you were not able to stop drinking once you had started? How often during the last year have you failed to do what was normally expected from you because of drinking? How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? How often during the last year have you had a feeling of guilt or remorse after drinking? How often during the last year have you been unable to remember what happened the night before because you had been drinking? Have you or somebody else been injured as a result of your drinking? Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down? N/A Never Monthly or less 2-4 times per month 2-3times per week 4+times per week N/A 1-2 3-4 5-6 7-9 10+ N/A Never Less than monthly monthly weekly daily or almost daily N/A Never Less than monthly monthly weekly daily or almost daily N/A Never Less than monthly monthly weekly daily or almost daily N/A Never Less than monthly monthly weekly daily or almost daily N/A Never Less than monthly monthly weekly daily or almost daily N/A Never Less than monthly monthly weekly daily or almost daily N/A Never Less than monthly monthly weekly daily or almost daily N/A No Yes but not in the last year yes, during the last year If you would like help in cutting down your alcohol intake please make an appointment at reception with our in house alcohol advisor who is Tamara Paul Tel 01274 809891 mobile: 07702 900654 Haigh Hall Medical Centre For Women: No Yes Details: When did you have a smear test last? ______________________ Are you using any contraception? ______________________ Are you pregnant or have you had a baby in the last 12 month? ______________________ No Yes Are you registered disabled? Are you registered blind or Partially sighted? Are you deaf/hard of Hearing Please give details: ______________________ ______________________ Do you care for somebody? Does someone care for you? Please give details:______________________ ______________________ Please give details:______________________ ______________________ Do you have a disability? Please give details: ______________________ ______________________ Please give details: ______________________ ______________________ Please give details: ______________________ ______________________ PATIENT NEXT OF KIN INFORMATION PATIENT NAME: NEXT OF KIN: ADDRESS: TEL NO: RELATIONSHIP: Haigh Hall Medical Centre PATIENT ETHNIC GROUP INFORMATION This practice, in line with other healthcare providers, collects information about the ethnic group that patients feel they belong to. You do not have to complete this form but if you do you will be helping us to help you. It will help us plan to deliver better services to our patients and ensure that everyone has equal access to the health care we provide. All the information we receive will be used and treated with the strictest confidence in the same way as any other information we hold. When used in the planning of services all names and other identifying details will be removed. If you have any queries about filling in this form , please ask a member of staff. Name: Date of Birth: What is your country of birth?_____________________ To which ethnic group do you feel you belong? (please tick) Asian Bangladeshi Indian Pakistani Asian other (please specify below) Caribbean Black other (please specify below) Mixed Race White and Asian White and Black African Please specify any other group Patient Refused Chinese other (please specify below) White British Irish White other (please specify below) Mixed Race White and Black Caribbean Other Mixed Race (please specify below) ________ What is your preferred spoken language?_________________________ Prefer not to say Do you require an interpreter? Yes No Do you require an interpreter for British sign language? Yes No What is your religion? __________________________ Prefer not to say Thank you for taking the time to complete this information