Portland Medical Practice
34 Portland Road, Kilmarnock, KA1 2DL.
Hurlford Clinic, Union Street, Hurlford, KA1 5BT.
Telephone No. : 01563 522411,
Fax : 01563 545499.
www.portlandmedicalpractice.co.uk
New Patient Medical
Please make sure you bring your completed forms, a urine sample and a form of ID to
your appointment.
If you are on repeat medications, please bring the repeat prescription request slip from your
previous practice with you.
IMPORTANT INFORMATION
Patients joining the Practice should be aware of our Practice Policy in relation to drugs which
can be abused or related to addiction problems.
The Practice will not issue the following drugs to new patients:o
o
o
o
Methadone
Dihydrocodeine
Diazepam
And other potentially addictive medications
We believe that such medications should only be supplied by the specialist addictions services;
there will be no exceptions to this rule.
New Patient Medical Form revised February 2011
Part 1 - to be completed by the patient or the patient’s representative. As your medical record can take
some time to arrive, please provide as much information as possible.
Surname
First Name(s)
Address
Date of Birth
Marital Status
Postcode
Telephone Number
CHI number
M/F
Employment Status
Are you a Carer with responsibility for a family member/friend/neighbour? Yes/No. If yes, please
complete a Carer Form at the reception desk – you will be asked if you wish to be referred for a Social
Services assessment.
Have you ever been registered with Portland Medical Practice before? Yes/No. If yes, please state
reason for leaving. Please note – if you have been removed from the Practice list at the Practice’s
request for aggressive behaviour, failing to attend appointments etc, you will not be re-registered.
Height
Weight
BP
Urine
Have you ever had any serious or significant illnesses or surgical procedures?
Date
Illness/Surgery
Date
Illness/Surgery
Please list any vaccinations that you have had and bring your Vaccination Card/Record
Date
Vaccine
Date
Vaccine
Date
Vaccine
Date
Vaccine
Date
Vaccine
Date
Vaccine
Please list any vaccines that you require or are overdue
Date due
Vaccine
Date due
Vaccine
Date due
Vaccine
2.
Do you have any allergies YES/NO
Medical history: please list any particular illnesses or diseases that run in your family, including details
of heart disease in parents/brothers/sisters and the approximate age at which it occurred. Are any other
Family members affected by serious illness at present?
Current Medication: please list all drugs/medicines that you are currently taking. Bring your current
medication and a repeat prescription order sheet if you have one when you come for your new patient
registration appointment.
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Do you take regular exercise Yes
Smoking Status
Never Smoked
Current Smoker-Amount per day (
)
No
Ex Smoker (date stopped)
We advise all smokers to stop smoking.
For advice see GP or contact Fresh
Ayrshire
01292 885827
Q.
Amount of Alcohol consumption per week?
Do you, or have you abused drugs YES (
) NO
Females of relevant age only
Last smear carried out
By:
Last breast examination
By:
Approx Date:
Approx date:
What is your ethnic origin?
Choose ONE section from A to E, tick the appropriate box to indicate your cultural
background.
A.
White
Scottish
Other British
Irish
Any other White background. Please specify …………………………………………
Main language spoken, please specify …………………Interpreter required Y/N…….
B.
Mixed
Any mixed background. Please specify ……………………………………….
Main language spoken, please specify ………………….Interpreter required Y/N……
C.
Asian, Asian Scottish or Asian British
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background. Please specify ……………………………………….
Main language spoken, please specify…………………Interpreter required Y/N…..
D.
Black, Black Scottish or Black British
Caribbean
African
Any other Black background
Please specify ………………………………….
Main language spoken, please specify …………………Interpreter required Y/N……..
E.
Other Ethnic background Please specify………………………………………….
Main language spoken, please specify…………………Interpreter required Y/N………