New Patient form

Surname:
Forename:
Maiden Name:
Date of Birth :
Address:
Postcode:
Telephone Home:
Telephone Work:
Occupation:
Spouses Occupation:
NHS Number:
Ethnicity:
Ethnicity Other:
Please specify any major illness or operations, with dates:
Have you suffered from:
Heart disease/Heart attack? Yes No
Strokes? Yes No
Blood pressure? Yes No
Diabetes? Yes No
Asthma? Yes No
Eczema/Hayfever? Yes No
Epilepsy? Yes No
Blindness/Glaucoma? Yes No
Cancer? Yes No
Depression/Psychosis? Yes No
Family medical history
Please specify age, any serious illness (if dead - age at death and cause)
Mother:
Father:
Brothers:
Sisters:
Have any of your parents, brothers or sisters suffered from:
Heart attack? Yes No
Angina? Yes No
Stroke? Yes No
High blood pressure? Yes No
Diabetes? Yes No
Cancer? Yes No
If yes, what type?

Do you drink alcohol Yes No
How many units per week?
1 unit = ½ pint of beer or 1 measure of spirits or 1 glass of wine.
Do you take regular exercise:
Please grade yourself on a scale of 1 to 10 where 1 = Avoid even trivial exercise and 10 = Competitive athlete.
Do you have a balanced diet? Yes No

Have you had a cervical smear in the last 3 years? Yes No
If yes, date and result:
Was the smear carried out at your doctors surgery? Yes No
If no, where?
Have you had a hysterectomy? Yes No
If yes, when and why?
Do you take the contraceptive pill? Yes No
If yes, which one?
Do you have a coil/IUD fitted? Yes No
If yes, when fitted and which type?
Are you pregnant Yes No
Remember, this practice provides family planning and well woman screening. Smear tests are carried out by our nurses.
After clicking submit below, please make an appointment for a 'New patient check' with our nurses. Thank you.