The Village Medical Centre

Please be sure you are from the practice core area before completing this form, please also complete as much of the form as possible as this information will assist the Health Authority in locating your notes. Items marked with an asterisk are mandatory.

Please fill in the form below:

Personal Details:

Title:

Previous surname:

Forename:

Other names:

Surname:

Marital status:

Occupation:

NHS Number:

Birth Details:

Country of birth:

Town of birth:

Date of birth: (DD/MM/YYYY)

Ethnicity:

White	Indian	Chinese	Black African	Other
Black Caribbean	Pakistani	Mediterranean	Bangladeshi

What is your primary spoken language?

Address Details:

House name:

House number:

Street:

Locality:

Town:

County:

Postcode:

Contact Details:

Phone (Home):

Phone (Work):

Phone (Mobile):

Fax:

Email address:

Previous Doctor: (Please give the name of your last doctor, even if you have not seem him/her for many years)

Doctors name:

Surgery name:

Surgery county:

Previous Address: (If you have not moved please enter your current address)

House name:

House number:

Street:

Locality:

Town:

County:

Postcode:

If you are from abroad:

Date you first entered the UK:

If you have always lived in the UK please enter N/A

Do you have any allergies?

Answer:

If you answered YES please give details below.

Smoking:

Have you ever been a regular smoker?
Do you currently smoke tobacco?
What type of tobacco do you smoke and how many per day?
Type:	Quantity:
Cigarettes
Pipe
Cigar
Roll Ups
Recreational Drugs

How much alcohol do you consume week? *

How often do you have a drink that contains alcohol?	Never	Monthly or less	2-4 times per month	2-3 times a week	4+ times a week
How many standard alcoholic drinks do you have on a typical day when you are drinking?	1-2	3-4	5-6	7-9	10+
How often do you have 6 or more standard drinks on one occasion?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily

How many units of the following alcohols do you consume within a week?

Wine:

Units

Beer:

Units

Spirits:

Units

Please indicate the type of exercise you participate in?

Type of exercise?	How often over a 4 week period of 20 mins or more
	0 times	1 to 4 times	5 to 11 times	12+ times
Enjoy light exercise
Enjoy moderate exercise
Enjoy heavy exercise
Competitive athlete
Attend exercise classes

Significant History:

Please list any important events, operations or serious illnesses you have had? Please provide an approximate year in which the event happened?

Current Medication:

Please list any medication which you are currently taking including dose and quantity as described on the lable?

Females Only

How many children have you had?
Have you had a hysterectomy?
When was your last smear test?
What was your last smear result?

Carer Information

Are you a carer?

if yes, who do you care for?

The Village Medical Centre
Kingswood Way
Great Denham
Bedford
MK40 4GH
Tel: 01234 244000
enquiries@gtdenham.org