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: Please select Mr Mrs Miss Ms Master Sir Dame Lord Dr. Professor Reverend Father Brother Sister Bishop Dean Honourable Rabbi Earl Major Colonel * Previous surname:   Forename: * Other names:   Surname: * Marital status: Please select Single Married Widowed Divorced Separated Unknown Engaged Co-habiting Remarried Stable relationship *   Occupation: Please select Top managers Management support Education/Health/Welfare Literary/Artistic/Sport Prof. Scientist/Engineering/Technology Managerial Clerical Selling/Retail Security/Protection Catering Farming/Fishing Materials processors Metal/Electrical Painters Inspector Construction/Mining Transport Other... 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: Yes No If you answered YES please give details below.       Smoking:   Have you ever been a regular smoker? Yes No Do you currently smoke tobacco? Yes No 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? 0 1 2 3 4 5 6 7 8 9 10 Please select Have you had a hysterectomy? Yes No Please select When was your last smear test? 6 Months Ago 1 Year Ago 2 Years Ago 3 Years Ago 4 Years Ago 5 Years Ago Never Please select What was your last smear result? Normal Abnormal Please select   Carer Information   Are you a carer? Yes No if yes, who do you care for? Parent(s) Son Daughter Friend Please select