Monkspath Surgery Health Data Form
The purpose of this form is to establish as much information about each patient as possible. This is
important because it can be several weeks before medical records are received from your previous
doctor. The information will be recorded on computer. You may ask to see the information held on
screen about you at any time. The practice is registered under the Data Protection Act. All information
will be strictly confidential.
Please complete a form for each member of the family registering with the practice. If you have
questions, a member of the reception staff will be happy to help.
If you are taking any regular medication, please make an appointment with one of the doctors to
discuss this.
Electronic transmission of prescriptions - If you have nominated a pharmacy at your previous
practice, please remember to update this nomination ASAP. If you wish to have your
prescriptions sent electronically to a participating pharmacy, please collect a form from
reception or your chosen pharmacy.
Registration Details
Surname:
Title : Mr / Mrs / Ms / Miss
First Names:
Date of Birth:
Address:
Home Tel no:
Work Tel No:
Mobile:
Email address:
Sex: Male / Female
Blood Group:
Please state any allergies (medicines, food, animals etc) :
Are you a carer or being cared for?
If you are a carer of a patient of this practice, please indicate the name and address of the
patient:
If you are being cared for, please give the name and contact number of your carer:
If you are a carer (whether of a patient at this practice, or elsewhere) and would like to discuss
your situation and consider the involvement of other agencies, please make an appointment to
see a doctor.
If you have a visual impairment, hearing loss or learning disability which you feel may affect
your access to the services at the surgery please do let us know so we can record any relevant
information about communicating with you on your records.
…………………………………………………………………………………………………..
Medical History
Please tick the box if you have suffered from any of the following:
Diabetes?

If so, do you use insulin? Yes / No
Asthma?

Angina?

Heart Attack?

Date:
High blood pressure?

Depression?




Epilepsy?
Hepatitis?
Stomach Ulcer?
Please tick if you have had the following:
Hysterectomy?

Date:
Vasectomy?

Date:
Family History
Does anyone in your immediate family suffer from:
Heart Disease ?
Stroke ?
YES / NO
YES / NO
High Blood Pressure?
If yes, what is their relationship to you?
If yes, what is their relationship to you?
YES / NO
If yes, what is their relationship to you
Smoking
Please circle
Smoker / Non Smoker / Ex smoker
If smoker, please state consumption. Number per day:…………… Cigarettes/ Cigars- please circle
If ex smoker, please state date stopped smoking ……………
Women Only (please answer those questions applicable to you)
When did you last have a cervical smear ?
What was the result?
Where was the test carried out ?
GP Surgery / Hospital / Clinic
Please give details of any pregnancies, including miscarriages:
Date
Method of Delivery
Details if child – sex / birth weight
Children Only
Please enter dates of the following immunisations:
Immunisation
Date given
Date given
Tetanus
Diphtheria
Pertussis
Hib
Polio
Pneumococcal
Meninigitis C
MMR
BCG
Other – please
indicate
Date given
Date given
Signature of patient (or representative if under 16):
Thank you for your help. Please return completed forms to the surgery.
Date given