New patient questionnaire - The Ridings Medical Group



New patient questionnaire

This questionnaire forms part of your registration process and must be completed before we can register you. New patients have the opportunity for a new patient appointment please ask at reception if you wish to book in for one of these appointments.

|Personal details |

|Name: | |Today’s Date: | |

|Date of Birth: | | | |

|Telephone No. (home) | |Telephone No. (work) | |

|Mobile No. | |Consent to text message reminders: |Yes ( No ( |

|I consent to receiving appointment confirmations, reminders and other notices via text messages and will update the Surgery of any |

|changes to my mobile number. I have read the terms and conditions.* |

|Signature | |Date | |

|Email Address | |

|Medical details |

|Height: | |Weight: | |

|Please use the Self check BP Machine or at Holme and Bubwith book Bp appt |

|Blood pressure (Age 40 and Over Only) BP …………./…………. Date taken: |

|Past medical history |

|Please detail any significant past medical | |

|history that you feel we should be informed of: | |

|Family history (Please indicate relationship and age at onset) |

|Please detail any significant family history that| |

|you feel we should be informed of (e.g. asthma, | |

|diabetes, epilepsy, stroke, heart attack, | |

|cancer): | |

|Medication – If you are on any repeat medication please book an appointment to see a GP before your next medication is due |

|Please list any prescribed medication you are |(Please attach a copy of your repeat prescription list if possible) |

|currently taking: | |

|Over the counter medication |

|Please list any over the counter medication that | |

|you take on a regular basis: | |

|Allergies (including drug allergies) |

|Please list any allergies you have: | |

|Lifestyle questions |

|Smoking status Please tick one of the following: |

|( Current smoker ( Ex-smoker ( Never smoked tobacco |

|If you are a current / ex-smoker, how many cigarettes/ ounces per day? |

|If you are an ex-smoker, what year did you give up smoking? |

|If you are a smoker there are various free stop smoking services in the Hull and East Riding areas. For further information and help on |

|quitting please call 0800 915 59 59 (freephone number). |

|Alcohol: units per week |

Alcohol Consumption Screen

Units of alcohol

| |1.5 | | | |

| | | | | |

| | | | | |

| | | | | |

|2 | |2 |1 |9 |

|Pint of beer, lager or |Alco pop or can of lager|Glass of wine 175ml |Single measure of spirit |Bottle of wine |

|cider | | | | |

|Questions |Scoring scheme |Enter score |

| | |below |

| |

|First Language: | |

|Country of Origin | |When did you last visit your country of origin? …… yrs |

|Have you ever served in the Armed forces? |Yes / No |

|Are you a carer of Yes / No |Are you housebound? Yes / No |

|An elderly or disabled person? | |

|ENHANCED SUMMARY CARE RECORD (ESCR) |

|The NHS in England has introduced the Summary Care Record, which will be used in emergency care. |

| |

|The record will only contain information about any medicines you are taking, medical history, allergies you suffer from and any bad reactions to |

|medicines you have had to ensure those caring for you have enough information to treat you safely. |

| |

|Your Summary Care Record will be available to authorised healthcare staff providing your care anywhere in England, but they will ask your permission |

|before they look at it. This means that if you have an accident or become ill, healthcare staff treating you will have immediate access to important |

|information about your health. |

| |

|If you would like an Enhanced Summary Care Record then you do not need to do anything and a Summary Care Record will be created for you. If you do |

|not want a Summary Care Record then tick the box and sign the opt out below. |

| |

|I do NOT want a Summary Care Record (tick Box) ( |

| |

|Signature: DATE: |

-----------------------

|WHITE |

|British | |

|Irish | |

|Any other white Background* | |

|ASIAN OR ASIAN BRITISH |

|Indian | |

|Pakistani | |

|Bangladeshi | |

|Any other Asian background* | |

|MIXED |

|White and Black Caribbean | |

|White and Black African | |

|White and Asian | |

|Any other mixed background | |

|BLACK OR BLACK BRITISH |

|Caribbean | |

|African | |

|Any other black background | |

|OTHER ETHNIC GROUPS |

|Chinese | |

|Any other ethnic group | |

|Decline to Specify | |

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