The Bush Doctors Surgery Patient Health Questionnaire
Please complete All questions on this form. If you need assistance with this form please ask a
member of staff.
Personal Details
Full Name:
Date of Birth:
Sex:
Occupation:
Telephone (home):
Telephone (work):
Mobile:
Email Address:
Next of Kin:
Relationship:
Tel:
Country of Origin:
Are you a refugee or are you seeking political asylum in the U.K.? Yes/No
Are you an entrant to the UK in the last 5 years? Yes/No
Were you born or have you lived or worked for more than one month in a country
recognised as a high risk for Tuberculosis? Yes/No
(High risk for Tuberculosis (TB) is everywhere except Canada/ USA/ Northern
Europe/Australia/ New Zealand).
__________________________________________________________________________________________________
*Main Language Spoken:
*Do you require an interpreter Yes/ No
*Please indicate your ethnic origin using the back page of this form.
Write the alphabet letter that appears beside your ethnic group in the space
above
__________________________________________________________________
*Are you a Carer? Yes/ No
Do you have a Carer? Yes/No
If you answered “yes” please ask for
If yes please provide the contact
a leaflet at reception
details of your Carer
Name:
Telephone No:
If you are registering a child under 16 please can you provide their school details;
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Childs name:
School:
Address:
Telephone No:
__________________________________________________________________
Lifestyle
What is your height?
*Do you smoke? Yes/No
What is your weight?
If yes, how many a day:
If no have you ever smoked?
Yes/No
If yes how many did you smoke
*Do you drink alcohol? Yes/No
If so how many units per week do
you consume:
e.g 1 glass of wine= 1 unit
1 half a pint= 1 unit 1 measure of spirit= 1 unit
Do you exercise at least 3 times a week Yes/No
Are you allergic to any drugs or medicines Yes/ No
Medical History
Please give details of any previous major illnesses, medical problems and
operations with dates:
…..…………………………………………………………………………………..
……………………………………………………………………………………….
If you are taking any regular medication please state name and dose:
………………………………………………………………………………………
………………………………………………………………………………………
If you are taking regular medication please make an appointment to see a GP
as prescriptions will not be issued if you have not seen a GP at the practice.
Have you had any vaccinations within the last 10
childhood immunisations:
…………………………………………………….
…………………………………………………….
…………………………………………………….
years? Please state and include
Date:
Date:
Date:
Do you, or have you suffered with any of these illnesses?
Asthma
Angina
Cancer
Stroke
Chronis Kidney
Disease(stages 3-5)
Atrial Fibrillation
Peripheral Arterial
Disease (PAD)
Coronary Heart Disease
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
No
No
Yes
No
Diabetes
Epilepsy
High blood pressure
Mental Illness
Transient Ischaemic
Attack (TIA)
Heart Failure
Familial
Hypercholesterolaemia
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
No
No
Family History
Please state any significant family medical history, e.g. heart disease
………………………………………………………………………………………
………………………………………………………………………………………
__________________________________________________________________
Well Woman
Are you using any contraception? If so please specify
Please note you will need to see a GP/nurse before any prescriptions will be issued)
*Have you had a smear Yes/ No
Date of test:
Result:
Place of procedure:
If ABROAD please state which country
Name of doctor/clinic:
What was the result?
When is your next test due? 3 years
(Please Circle)
12 months
6 months
Do you have a copy/ letter stating the result?
Have you had an abnormal smear?
Have you ever had a Hysterectomy? Yes/ No
If “yes” when and where?
Was it a Total Hysterectomy?
Yes/ No
__________________________________________________________________
We appreciate the time you have taken to complete this form. The
information you have provided will be valuable in assessing any health needs
that you may have. If you have any queries about this form, please contact the
Practice Manager.
Name………………………
Signature……………………….
Date…………….
_______________________________________________________________________
NB: The Hammersmith and Fulham PCT recognises that informal carers provide
an invaluable service and in partnership with the LBHF they are keen to ensure that
carers are provided with all the support and information available to help them. To
this effect, please state if you are an informal carer of if you have a carer, if yes,
then please provide carers name……………………………………………………..
Patient records are held on the computer as well as paper. GP’s are
responsible for the confidentiality of these records. On occasion, we share
information from the patient records with the Heath Authority, the local
Primary Care Group/ Trust, hospitals and other NHS/ partner organisations
in the interests of patient care.
I agree to my medical records being held under the above terms and I certify
that the information I have provided is correct to the best of my knowledge.
Name……………………… Signature……………………….
Date……………
Recording of Ethnic Group Information for Patients
This practice, in line with other healthcare providers, collects information about the
ethnic group of patients. This information can help us plan to meet the needs of the
community and ensure that everyone has equal access to the healthcare we provide.
Please note that we are not asking about citizenship or nationality, but about the ethnic
group which you feel you belong to.
All the information we receive will be used and treated with the strictest confidence.
Any planning information on general release will be anonymous with all names
removed.
The classification is entirely voluntary but will help us to provide a better service. The
level of care you will be offered at this practice will not be affected by decision to
complete this form.
If you have any queries about completing this form please ask a member of staff.
Otherwise use this as a guide to fill in the questionnaire. If you feel you are descended
from more than one ethnic group, please select the one that you feel you most belong to
or chose the ‘Any other ethnic group’ and specify the ethnic groups
Many thanks
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
P.
Q.
White
British/ Mixed
White
Irish
White
Any other background
Mixed
White and Black Caribbean
Mixed
White and Black African
Mixed
White and Asian
Mixed
Any other mixed background
Indian or Indian British
Pakistani or Pakistani British
Bangladeshi or Bangladeshi British
Other Asian
Caribbean
African
Chinese
Any other black background
Indian
Refused/ Not stated
The Bush Doctors Surgery Registration Policy
All non NHS services will incur charges depending upon the services requested. The
current fees are available from reception upon request.
If you change your address, or telephone number please let us know as important
correspondence from our Practice may be missed.
Please note that for the first seven days of your sickness a private sick certificate can be
issued but will incur a charge.
Request for repeat medications are not accepted over the phone. Please use a stamped
addressed envelope or come in to the surgery in person. 48 hours notice is required for
this service.
To speak to the Doctor please ring before 12.30pm and leave a message for the doctor to
call you back. All non urgent calls received after 12.30pm will not be dealt with until
the following day.
RUDENESS AND AGGRESSIVE BEHAVIOUR WILL NOT BE TOLERATED
AND WILL RESULT IN INSTANT REMOVAL FROM THE DOCTORS LIST
I (please insert your name)……………………………………………………………….
of (please insert address)…………………………………………………………………
agree to comply with the above conditions of my registration at The Bush Doctors
Surgery
Patient signature…………………………………
Date………………………….
AUDIT C
Questions
Your
Score
Scoring System
How often do you have a drink containing
alcohol?
0
Never
1
Monthly
or less
2
2-4
times
per
month
3
2-3
times
per
week
4
4+
times
per
week
How many units of alcohol do you drink on
a typical day when you are drinking?
1-2
3-4
5-6
7-9
10+
How often have you had 6 or more units if
female, or 8 or more if male, on a single
occasion in the last year?
Never
Less
than
monthly
Monthly
Weekly
Daily
or
almost
daily
Scoring:
A total of 5+ indicates increasing or higher risk drinking
An overall total score of 5 or above is AUDIT C positive
Brief Advice Tool
This is one unit…..
SCORE