Registration Checklist

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1 Registration Checklist Please can you fully complete the attached registration fms, and return to the surgery as soon as possible. When completing your fms, please ensure that you have entered your NHS number and the date that you fist came to live in the U.K (if you were bn outside of the U.K). Once you have fully completed your registration fms, please return them to the surgery with the following iginal fms of I.D: Passpt / Birth Certificate Visa (If bn outside of the E.U) Utility Bill / Bank Statement (As proof of address) NHS card / number Received by staff member: (Please initial) Please note: We will not accept a completed registration fm without the above listed identification. Please contact reception if you have any queries regarding the above infmation. In der to complete your registration process, you will need a new patient health check with our Health- Care Assistant. Please ensure you book this with Reception. FOR ADMIN USE ONLY Registered onto EMIS Ethnicity Smoking Status FAST alcohol sce Please tick to confirm entered onto EMIS New Patient Questionnaire Version 4 (March 2013) 1

2 New Patient Questionnaire Our docts would like to invite you to fill in this questionnaire. Some of this infmation will go on to our clinical computer systems. This infmation will be treated with the utmost confidentiality. Name Personal Details Address Post Code Date of Birth Telephone Number Mobile Number Address Height Weight Past Medical Histy (please circle) Asthma YES Epilepsy YES High Blood Pressure YES Heart Problems YES Diabetes YES Please Detail: Diet Controlled/ Insulin Controlled (Type 1) / Diet and tablets (Type 2) Please detail any other significant past medical histy that you feel we should be infmed of? New Patient Questionnaire Version 4 (March 2013) 2

3 Family Histy Mother Condition Father Brother Please detail any significant family histy that you feel we should be infmed of? (e.g. Asthma, Diabetes, Epilepsy, Stroke, Heart Attack) Sister Aunt Uncle Grandmother (Mothers Side) Grandfather (Mothers Side) Grandmother (Fathers Side) Grandfather (Fathers Side) Life Style Questions Do you smoke cigarettes? If yes, how many cigarettes per day? Do you smoke tobacco? If you smoke would you like smoking cessation advice? If you are an ex smoker, what year did you give up? Do you drink alcohol? If yes, how many units per week? YES NO New Patient Questionnaire Version 4 (March 2013) 3

4 How would you describe yourself? White British White Irish Any other white background Mixed White & Black Caribbean Mixed White & Black African Mixed White & Asian Mixed Any other mixed background Asian Asian British - Indian Prefer not to state ethnicity Asian Asian British - Pakistani Asian Asian British - Bangladeshi Asian Asian British Any other Asian Background Black Black British - Caribbean Black Black British - African Black Black British Any other black background Other Ethnic Groups Chinese Other Ethnic Groups Any other ethnic group? First Language spoken Can you speak English Do you require an interpreter? Thank you f your cooperation New Patient Questionnaire Version 4 (March 2013) 4

5 FAST Please complete this questionnaire by circling your answer. Questions How often have you had 6 me units if female, 8 me if male, on a single occasion in the last year? Scing system Your sce How often during the last year have you failed to do what was nmally expected from you because of your drinking? How often during the last year have you been unable to remember what happened the night befe because you had been drinking? Has a relative friend, doct other health wker been concerned about your drinking suggested that you cut down? No Yes, but not in the last year Yes, during the last year New Patient Questionnaire Version 4 (March 2013) 5

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