Patient Details
Title
Date of Birth
Occupation
Mr Mrs Miss Ms Surname
First Names
Previous Surnames
Home Address:
Post Code:
Tel No: Mobile:
Name and Address of Previous GP:
Ethnic Group
Work:
White
Black
Asian
British
Irish
Other (Please specify)
Caribbean
African
Other (Please specify)
Mixed
Language
Indian
Pakistani
Chinese
Other (Please specify)
White & Black Caribbean
White & Black African
White & Asian
Other (Please specify)
What is your first language?
Proof of Identity
Birth Certificate
Allowance Book
Driving Licence Passport Utility Bill
Solicitor’s Letter Offer of Tenancy Other
Please list any medications being taken and the dosages:
Are you registered disabled? Yes No
If yes please give details of your disability: ……………………………………………………………………………
………………………………………………………………………………………………………………………………

Medical Information
Please list any serious illnesses/operations/accidents/disabilities (and for women, pregnancy related problems) and the year they took place.
Have you ever suffered from? (tick as appropriate)
Epilepsy Yes No Blindness/Glaucoma
High Blood Pressure
Heart Attack/Stroke
Yes
Yes
No
No
Diabetes
Depression
Cancer
Eczema/Hay Fever
Yes No Asthma
Yes No
Are you allergic to any medicines and if so, which ? Yes No
Yes No Have you ever refused treatment/screening of any kind, and if so what?
Women
Yes
Yes
Yes
Yes
No
No
No
No
Have you ever had a cervical smear? Yes No
If yes please state when and where: ………..…………………………………………………………………………
………………………………………………………………………………………………………………………………
Do you smoke?
If no, have you ever smoked?
Yes
Yes
No
No
If yes how many cigarettes or ounces of tobacco per week? ………………………………………………………
Yes No Would you like advice on giving up smoking?
How much alcohol do you drink in a week? units
(1 unit = ½ pint beer, 1 small glass of wine, 1 single spirit, 1 small glass of sherry or 1 single aperitif)
OVER 16’s ONLY
Alcohol Users Disorders Identification Test (AUDIT) C
Questions
0 1
Never Monthly or less
Scoring System
2
2-3 times per month
3
2-3 times per week
4
4+ per week
Your
Score
How often do you have a drink that contains alcohol?
How many standard alcoholic drinks do you have on a typical day when you are drinking?
How often do you have 6 or more standard drinks on one occasion?
Your height:
1-2 3-4
Never Less than monthly
5-6
Monthly
Your weight:
7-8
Weekly
10+
Daily or almost daily

Family History
Please state any serious illness, in particular heart disease, strokes, high blood pressure, diabetes or any inherited disease:
………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………….
For Patients aged 65 and over
Please give name, address and telephone number of next of kin:
………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………….
For Patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)
Have you had a flu vaccination? Enter date or ‘never’
Have you had a pneumococcal vaccination? Enter a date or ‘never’
Other information
Do you have a carer? Yes No
If yes please give details of your carer: ………..…………………………………………………………………………..
………………………………………………………………………………………………………………………………….
Are you a carer? Yes No
If yes please give details of who you care for: ..…………………………………………………………………………..
………………………………………………………………………………………………………………………………….
Do you hold a living will?
Signature:
Yes No
(Documentation regarding your personal wishes in respect of medical intervention at the time of serious illness)
Date: