NHS IN SCOTLAND



|NEW PATIENT QUESTIONNAIRE |

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|Name: |  |  |  | | |

|Address: |  |  |  |  | |

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|Postcode: |  |Telephone: |  | | |

|Date of Birth: |  |Mobile: |  |  | |

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|MEDICAL HISTORY |

|Have you or any members of your immediate family had any of the following illnesses? |

|  |YOU |MOTHER |FATHER |SISTER |BROTHER |

|Asthma |  |  |  |  |  |

|Chest Problems |  |  |  |  |  |

|Diabetes |  |  |  |  |  |

|Heart Problems |  |  |  |  |  |

|High Blood Pressure |  |  |  |  |  |

|High Cholesterol |  |  |  |  |  |

|Stroke |  |  |  |  |  |

|Thyroid Disease |  |  |  |  |  |

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|Please list any other relevant information including major illnesses or operations you have had: |

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| | |MEDICATION | | | |

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|Please list any medications you are prescribed regularly: |

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|ALLERGIES |

|Please list any medicines you are allergic to: |

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|Tetanus Status: |When did you last have a tetanus vaccination? __________ |

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|Smoking Status: |Do you smoke? |Yes_____ No_____ Ex-smoker_____ | |

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|Alcohol Intake : |Current drinker: |Yes_____ No_____ Units per week:_____ | |

| |Lifelong Teetotaller: _____ | | | |

| |Ex-drinker: _____ | | | |

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|Exercise: |Please tick which best describes how you exercise: | |

| |Exercise physically impossible_____ |once a week_____ most days_____ |

| |No form of regular exercise_____ |3 times a week_____ | |

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|Women Only: |Have you had a hysterectomy? Yes_____ No_____ | |

| |If not, when was your last smear ______________ | |

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|Children Only: |Please list any childhood vaccinations below |

FINLAYSON STREET SURGERY : PATIENT QUESTIONNAIRE

This short questionnaire will give surgery staff some basic information about your communication support needs and ethnicity to support your health care.

Name ……………………………………………….. DOB _ _ / _ _ / _ _

Do you need an interpreter or sign language support? Yes No

If you do need an interpreter what language do you speak?

Please state …………………………………………………….

What is your ethnic group?

Choose ONE section from A to E then tick ONE box which best describes your ethnic group or background

A White

□ Scottish

□ English

□ Welsh

□ Northern Irish

□ British

□ Irish

□ Gypsy/Traveller

□ Polish

□ Any other white ethnic group, please write in …………………………………..

   

B Mixed or multiple ethnic groups

□       Any mixed or multiple ethnic groups 

C Asian, Asian Scottish or Asian British

□    Pakistani, Pakistani Scottish or Pakistani British

□     Indian, Indian Scottish or Indian British

□     Bangladeshi, Bangladeshi Scottish or Bangladeshi British

□    Chinese, Chinese Scottish or Chinese British

□   Other, please write in……………………………………………….

D African, Caribbean or Black

□       African, African Scottish or African British

□       Caribbean, Caribbean Scottish or Caribbean British

□   Black, Black Scottish or Black British

□   Other, please write in…………………………………………………………………

E Other ethnic group

□     Arab

□    Other, please write in………………………………………………………………..

If you do not wish to give this information, please tick here

Finlayson Street Surgery - Key Information Summary (KIS) consent

General practice patient records contain confidential information which is not available to anyone who works outwith the practice.

There is however certain key information within the records which can at times be very useful to those involved in your care such as Health Professionals working at GMEDS, A+E, hospital admissions and the ambulance service.

The Key Information Summary (KIS) usually contains information about:

← Medication

← Allergies and reactions to medicines

← Contact information

← Care plans

← Next of kin and carer details

← Wishes or special instructions

← Management plans if you have a long term condition (such as diabetes)

← Preferred place of care

← Consultations (or their content) with your GP or nurse are NOT part of KIS

Benefits of the Key Information Summary (KIS) include:

← The Key Information Summary will be available quickly for NHS staff in Out of Hours and Accident & Emergency.

← Patients will be able to include wishes and special instructions

← Patients will be able to record their preferred place of care

The Key Information Summary would be accessed and used in emergency situations or if you required Out of Hours care when your GP Practice is closed. In addition, the information can be seen by Ambulance paramedics and hospital clinics. The information is not shared or accessible to any other groups e.g. social workers.

Please complete the form below and hand it back in at the reception desk.

If you have any further questions or information you would like us to add to your summary please make a routine phone appointment with your usual GP to discuss this.

Name: ...............................................................................................................................

Date of Birth: ........................................

Address: ..........................................................................................................................

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□ I give consent for my key information summary (KIS) to be accessed.

□ I do not give consent for my key information summary (KIS) to be accessed

Signature: .................................................................................. Date: ....................

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