WIDCOMBE SURGERY
PERSONAL MEDICAL HISTORY
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SURNAME:
FORENAMES:
ADDRESS:
POSTCODE:
DATE OF BIRTH:
MOBILE/TELEPHONE NUMBER:
OCCUPATION:
Medicines taken regularly
Allergies
Height……………………………………
Weight……………………………………
Past Illnesses/ Accidents/ Operations
Year
Illness/ Accident/ Operation
Smoking (circle as appropriate)
Never Smoked
Cigarette Smoker
Pipe Smoker
Cigar Smoker
Rolled Cigarette Smoker
Average amount smoked per day……………
Ex Smoker
Average past amount smoked…………Age Started…………Age Stopped……...
Alcohol
Average units consumed per week……………
(2 units = 1 glass of wine or 1 measure of spirits – 3 units = 1 pint of beer/larger)
Family History
Have any blood relatives suffered from
Diabetes
Breast Cancer
Yes/No
Yes/No
Glaucoma
Stomach Cancer
Yes/No
Yes/No
Asthma
Yes/No
Colon Cancer Yes/No
And before Age of 60
Angina/ Heart Attack Yes/No
High Blood Pressure Yes/No
Stroke
Yes/No
Female Patients
History of pregnancies and miscarriages
Year
Duration (weeks)
Baby’s Weight
Complications
Do you wish to register for contraceptive advice?
Current contraception used………………………………………...
Have you ever had a cervical smear?
Date and result of last test……………………………………...
If you need to give more details on any of the above, please continue over the page.
WIDCOMBE SURGERY
REQUEST FOR FURTHER DETAILS
For our records we ask that you provide us with the following:
Next of kin or ‘in case of need’ contact
NAME:
RELATIONSHIP TO YOU:
HOME Tel:
WORK Tel:
MOBILE:
EMAIL ADDRESS:
Any other useful information that you feel would be of benefit to the practice:
Do you look after someone? YES / NO
Does someone look after you? YES / NO
if yes…for who:
if yes...who does:
Ethnic Origin
The Health Authority ask us to obtain the following information from you – although please note
that this is optional: (please tick only one and specify further information if appropriate e.g. Any
other white: specify: Italian)
White
( ) British or mixed British
( ) Irish
( ) Any other White (e.g. European nationality, white commonwealth etc)
specify…………………………………………
Mixed
(
(
(
(
) White+ Black Caribbean
) White + Black African
) White + Asian
) Any other mixed background – specify……………………………………
Asian/Asian British ( ) Indian
( ) Pakistani
( ) Bangladeshi
( ) Any other Asian background – specify……………………………………
Black/Black British ( ) Caribbean
( ) African
( ) Any other Black background – specify……………………………………
Other ethnic group ( ) Chinese
( ) Any other ethnic group – specify……………………………………
Not stated
( )
WIDCOMBE SURGERY
Registering New Patients
Registering Patients Supporting Documentation
For verification of new patients’ identity and address the following documentation may be
acceptable
At Least one document as proof of identity from the following list:
Passport
UK driving licence (with photo)
HM Forces ID card (UK)
EU national identity card
Firearms licence (UK)
Adoption certificate (if applicable)
NB. Birth certificates are NOT acceptable as proof of identity.
If the patients is wishing to register as a spouse of an ordinary resident, then
a Marriage or civil partnership certificate may be accepted as proof.
PLUS
At least one document as proof of address from the list below:
P45/P60 statement (UK)
Bank/Building Society statement
Utility Bill e.g. Electric, gas, water, telephone bill
TV licence
Credit Card statement
Mortgage statement
Rent book/ Tenancy agreement
Insurance certificate
Council Tax statement (UK)
Addressed payslip
NHS Card (UK)
Benefit statement (e.g. child allowance, pension, tax credits)
Work permit/visa (UK)
Certificate of British Nationality (UK)
One of the following documents from the Borders and Immigration Agency (BIA)
- Convention Travel Document (CTD)
- Stateless Person’s Document (SPD)
- Asylum Registration Card (ARC)
For overseas students:
A letter from an educational establishment (e.g. College, University)
confirming enrolment on a course of study for 6 months or longer.